Provider Demographics
NPI:1164458485
Name:BIASOTTO, NICHOLAS OLIVER (DO)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:OLIVER
Last Name:BIASOTTO
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 1:620 STANTON-CHRISTIANA RD,
Mailing Address - Street 2:STE 205
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713
Mailing Address - Country:US
Mailing Address - Phone:302-998-1284
Mailing Address - Fax:302-998-1267
Practice Address - Street 1:620 STANTON-CHRISTIANA RD,
Practice Address - Street 2:STE 205
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-998-1284
Practice Address - Fax:302-998-1267
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0002000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000196003Medicaid
B66495Medicare UPIN
DEB66495Medicare UPIN
129882Medicare ID - Type Unspecified