Provider Demographics
NPI:1093944647
Name:NICOLOSI, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:NICOLOSI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 GUY LOMBARDO AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3714
Mailing Address - Country:US
Mailing Address - Phone:516-377-3332
Mailing Address - Fax:516-377-3844
Practice Address - Street 1:73 GUY LOMBARDO AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3714
Practice Address - Country:US
Practice Address - Phone:516-377-3332
Practice Address - Fax:516-377-3844
Is Sole Proprietor?:No
Enumeration Date:2009-07-03
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2446831174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist