Provider Demographics
NPI:1790735132
Name:MACRI, NICODEMO (MD)
Entity Type:Individual
Prefix:
First Name:NICODEMO
Middle Name:
Last Name:MACRI
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 1:2255 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4315
Mailing Address - Country:US
Mailing Address - Phone:850-386-4054
Mailing Address - Fax:
Practice Address - Street 1:2255 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-386-4054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68962208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG12886Medicare UPIN