Provider Demographics
NPI: | 1619170552 |
---|---|
Name: | HILLIARD, NICHOLAUS JACK (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | NICHOLAUS |
Middle Name: | JACK |
Last Name: | HILLIARD |
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: | 5700 SOUTHWYCK BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | TOLEDO |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 43614-1509 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 800-288-8325 |
Mailing Address - Fax: | 419-866-5453 |
Practice Address - Street 1: | 5149 N 9TH AVE |
Practice Address - Street 2: | |
Practice Address - City: | PENSACOLA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32504-8779 |
Practice Address - Country: | US |
Practice Address - Phone: | 850-416-6303 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-06-07 |
Last Update Date: | 2016-02-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AL | 25024 | 207ZD0900X |
FL | ME 101330 | 207ZH0000X |
FL | 101330 | 207ZP0102X |
FL | ME101330 | 207ZP0102X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No | 207ZD0900X | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
No | 207ZH0000X | Allopathic & Osteopathic Physicians | Pathology | Hematology |