Provider Demographics
NPI:1548213697
Name:NICOSIA, ROGER JULIAN JR (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:JULIAN
Last Name:NICOSIA
Suffix:JR
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 1:1050 SE MONTEREY RD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4512
Mailing Address - Country:US
Mailing Address - Phone:772-678-7043
Mailing Address - Fax:772-403-2379
Practice Address - Street 1:1050 SE MONTEREY RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4512
Practice Address - Country:US
Practice Address - Phone:772-678-7043
Practice Address - Fax:772-403-2379
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5396207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHN642ZMedicare UPIN
D41850Medicare UPIN