Provider Demographics
NPI:1164787834
Name:NICOLAU, MARK JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JONATHAN
Last Name:NICOLAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:2649 SCHOENERSVILLE RD STE 202
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-7316
Practice Address - Country:US
Practice Address - Phone:484-884-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD461321208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery