Provider Demographics
NPI:1093822736
Name:NICOLETTO, JOSEPH PETER (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:PETER
Last Name:NICOLETTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 LOUISIANA AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2159
Mailing Address - Country:US
Mailing Address - Phone:406-283-6800
Mailing Address - Fax:406-293-2936
Practice Address - Street 1:308 LOUISIANA AVE STE 1
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2159
Practice Address - Country:US
Practice Address - Phone:406-283-6800
Practice Address - Fax:406-293-2936
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6707208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT98531OtherBC/BS
MT0042585Medicaid
MT0042585Medicaid