Provider Demographics
NPI:1164461810
Name:CAVALLI, NINA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:NINA
Middle Name:ANN
Last Name:CAVALLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5027 VANTAGE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-7564
Mailing Address - Country:US
Mailing Address - Phone:201-693-7034
Mailing Address - Fax:201-768-3840
Practice Address - Street 1:5027 VANTAGE CT
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-7564
Practice Address - Country:US
Practice Address - Phone:201-693-7034
Practice Address - Fax:201-768-3840
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143314208D00000X
NJ25MA06395900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
099194CSOMedicare ID - Type Unspecified
H76134Medicare UPIN