Provider Demographics
NPI:1376532895
Name:MONTICCIOLO, NATALIE LAMA (DO)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:LAMA
Last Name:MONTICCIOLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5091 LITTLE ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653
Mailing Address - Country:US
Mailing Address - Phone:727-849-1447
Mailing Address - Fax:727-849-3208
Practice Address - Street 1:5091 LITTLE ROAD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653
Practice Address - Country:US
Practice Address - Phone:727-849-1447
Practice Address - Fax:727-849-3208
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7718174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06885OtherBLUE CROSS BLUE SHIELD
FL106357874OtherRAILROAD MEDICARE
FL106357874OtherRAILROAD MEDICARE
FLH56688Medicare UPIN
FL06885ZMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL