Provider Demographics
NPI:1811423858
Name:ROSS-GREENBAUM, NICOLE AMANDA (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:AMANDA
Last Name:ROSS-GREENBAUM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 SW 117TH AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-4825
Mailing Address - Country:US
Mailing Address - Phone:786-467-3140
Mailing Address - Fax:
Practice Address - Street 1:8200 SW 117TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-4825
Practice Address - Country:US
Practice Address - Phone:305-279-7677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS16803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program