Provider Demographics
NPI:1922376847
Name:NICOULA, MICHAEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:NICOULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1345 W BAY DR STE 202
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2276
Mailing Address - Country:US
Mailing Address - Phone:727-559-0895
Mailing Address - Fax:727-518-7633
Practice Address - Street 1:1345 WEST BAY DIRVE
Practice Address - Street 2:SUITE 202
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2276
Practice Address - Country:US
Practice Address - Phone:727-559-0895
Practice Address - Fax:727-518-7633
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME114094207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009156900Medicaid
FL009156900Medicaid