Provider Demographics
NPI:1568487478
Name:MICOLUCCI, VICTOR C (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:C
Last Name:MICOLUCCI
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:11513 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4002
Practice Address - Country:US
Practice Address - Phone:904-751-6200
Practice Address - Fax:904-751-1600
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47620207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLKP219OtherMEDICARE
FL59980OtherBCBS
FL042213400Medicaid