Provider Demographics
NPI:1205891256
Name:NICOLA, JOSE ALFREDO (IDC)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ALFREDO
Last Name:NICOLA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 BUCCANEER DR APT A
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-7047
Mailing Address - Country:US
Mailing Address - Phone:847-730-5246
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HEALTH CLININC GREAT LAKES
Practice Address - Street 2:BRANCH MEDICAL CLINIC 1007 USS TRANQUILITY
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:847-688-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman