Provider Demographics
NPI:1508294117
Name:URDIALES, NICHOLAS R
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:R
Last Name:URDIALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3654 CORINTH PKWY
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76208-5373
Mailing Address - Country:US
Mailing Address - Phone:973-789-5148
Mailing Address - Fax:
Practice Address - Street 1:1767 LAKEWOOD RANCH BLVD
Practice Address - Street 2:#252
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-4906
Practice Address - Country:US
Practice Address - Phone:973-789-5148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist