Provider Demographics
NPI:1205978434
Name:NICOLAIS, VINCENT MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:MICHAEL
Last Name:NICOLAIS
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 1:5110 MIDLAND TRCE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-3426
Mailing Address - Country:US
Mailing Address - Phone:706-561-4992
Mailing Address - Fax:706-561-4992
Practice Address - Street 1:710 CENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1527
Practice Address - Country:US
Practice Address - Phone:706-571-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT17941207RC0200X
GA34676207RC0200X
NY131631207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00462789CMedicaid
C05668Medicare UPIN
GA00462789CMedicaid