Provider Demographics
NPI:1427189448
Name:NIMMONS, TREVOR THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:THOMAS
Last Name:NIMMONS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3118
Mailing Address - Country:US
Mailing Address - Phone:321-795-2273
Mailing Address - Fax:321-253-0212
Practice Address - Street 1:1751 SARNO RD
Practice Address - Street 2:STE 3
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4909
Practice Address - Country:US
Practice Address - Phone:321-795-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 8272204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI 43858Medicare UPIN
FL02251Medicare ID - Type Unspecified