Provider Demographics
NPI:1982646410
Name:NICOLAS, FRED (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:NICOLAS
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 1:766 DANIEL ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3502
Mailing Address - Country:US
Mailing Address - Phone:631-391-7887
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:766 DANIEL ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3502
Practice Address - Country:US
Practice Address - Phone:718-240-5077
Practice Address - Fax:718-240-6621
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109349208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00193917Medicaid
NY00193917Medicaid
NY962681Medicare ID - Type Unspecified