Provider Demographics
NPI:1659570851
Name:CODOLOSA, JOSE NICOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:NICOLAS
Last Name:CODOLOSA
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 1:5398 PARK ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-1041
Mailing Address - Country:US
Mailing Address - Phone:727-544-1441
Mailing Address - Fax:757-545-8263
Practice Address - Street 1:5398 PARK ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-1041
Practice Address - Country:US
Practice Address - Phone:727-544-1441
Practice Address - Fax:757-545-8263
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121995207RC0000X
PAMD440327207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014728800Medicaid
FL014728800Medicaid