Provider Demographics
NPI:1710084231
Name:OVERDIEK, NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:OVERDIEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7434 S SEAGRAPE RD
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33955-1037
Mailing Address - Country:US
Mailing Address - Phone:941-916-4384
Mailing Address - Fax:
Practice Address - Street 1:809 E MARION AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3819
Practice Address - Country:US
Practice Address - Phone:941-637-2580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79103207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35928OtherBLUE SHIELD
BO6853774OtherDEA
H25899Medicare UPIN
FL35928Medicare ID - Type Unspecified