Provider Demographics
NPI:1396820668
Name:NICOSIA, ANTHONY PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:PETER
Last Name:NICOSIA
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:PO BOX 8540
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-8540
Mailing Address - Country:US
Mailing Address - Phone:772-332-1757
Mailing Address - Fax:772-777-3044
Practice Address - Street 1:1502 SE HOLIDAY RD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5416
Practice Address - Country:US
Practice Address - Phone:772-332-1757
Practice Address - Fax:772-777-3044
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91689207Q00000X, 207QA0000X, 207QA0505X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278035600Medicaid
NJ0940704Medicaid
FL278035600Medicaid
NJ0940704Medicaid
FLU4211Medicare ID - Type UnspecifiedMEDICARE ID NUMBER