Provider Demographics
NPI:1669634010
Name:AGRESTI, NICHOLAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:J
Last Name:AGRESTI
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 1:4800 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6004
Mailing Address - Country:US
Mailing Address - Phone:904-398-7205
Mailing Address - Fax:
Practice Address - Street 1:3 SHIRCLIFF WAY STE 400
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4780
Practice Address - Country:US
Practice Address - Phone:904-381-9393
Practice Address - Fax:904-381-9314
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115292207RG0100X
CT4108003429207R00000X
GA068471207RG0100X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111490100Medicaid
GA003126825GMedicaid
SCGA1380Medicaid
707853OtherWELLCARE
GA003126825AMedicaid
01706047OtherAMERIGROUP
GAP01089555OtherRAILROAD MEDICARE
GA003126825CMedicaid
GA003126825AMedicaid