Provider Demographics
NPI:1275738171
Name:NICOSON, MICHAEL CARL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CARL
Last Name:NICOSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 MOCKINGBIRD HILL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-1852
Mailing Address - Country:US
Mailing Address - Phone:502-631-0601
Mailing Address - Fax:855-852-7155
Practice Address - Street 1:2400 EASTPOINT PKWY
Practice Address - Street 2:SUITE 570
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4154
Practice Address - Country:US
Practice Address - Phone:502-631-0601
Practice Address - Fax:855-852-7155
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074143A2082S0105X
KY472772082S0105X
MO2007015040208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK146710Medicare PIN
IL218440002Medicare PIN