Provider Demographics
NPI:1396792867
Name:NICOLEAU, CARL A (MD PHD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:A
Last Name:NICOLEAU
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 SEAGIRT BLVD
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2803
Mailing Address - Country:US
Mailing Address - Phone:718-565-6880
Mailing Address - Fax:877-796-4457
Practice Address - Street 1:2008 SEAGIRT BLVD
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2803
Practice Address - Country:US
Practice Address - Phone:718-565-6880
Practice Address - Fax:877-796-4457
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141096207RS0012X
NY180270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY180270OtherSTATE LICENSE
NY01454842Medicaid
NY180270OtherNYS MEDICAL LIC #