Provider Demographics
NPI:1205044476
Name:MAVRIDES, NICOLE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ANN
Last Name:MAVRIDES
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 1:1120 NW 14TH ST
Mailing Address - Street 2:SUITE 1466
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-2107
Mailing Address - Country:US
Mailing Address - Phone:305-243-2861
Mailing Address - Fax:305-243-8532
Practice Address - Street 1:1120 NW 14TH ST
Practice Address - Street 2:SUITE 1466
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-2107
Practice Address - Country:US
Practice Address - Phone:305-243-2861
Practice Address - Fax:305-243-8532
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2501672084P0804X
FLME 1115032084P0804X, 2084P0015X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY250167OtherNY STATE LICENSE
FLME 111503OtherFL STATE LICENSE
FL004138900Medicaid