Provider Demographics
NPI:1932127768
Name:NICKERSON, GERALD L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:L
Last Name:NICKERSON
Suffix:JR
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 1:280 VILLORESI BLVD
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-1987
Mailing Address - Country:US
Mailing Address - Phone:337-257-4454
Mailing Address - Fax:813-406-5195
Practice Address - Street 1:333 TAMIAMI TRL S STE 101
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285
Practice Address - Country:US
Practice Address - Phone:941-375-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95990208100000X, 2081P2900X
LA11047R208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1999989Medicaid
FL277901300Medicaid
A85674Medicare UPIN
FL277901300Medicaid
FLAG342YMedicare PIN