Provider Demographics
NPI:1225182975
Name:NICOLESCU-NICHOLS, JULIET A (MD)
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:A
Last Name:NICOLESCU-NICHOLS
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 1:125 OAKLAND AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2130
Mailing Address - Country:US
Mailing Address - Phone:631-928-3122
Mailing Address - Fax:631-928-3192
Practice Address - Street 1:125 OAKLAND AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2130
Practice Address - Country:US
Practice Address - Phone:631-928-3122
Practice Address - Fax:631-928-3192
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2143372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02182089Medicaid
5R1131Medicare ID - Type Unspecified
NYH47334Medicare UPIN