Provider Demographics
NPI:1750359063
Name:DENICOLA, LUCIAN KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:LUCIAN
Middle Name:KENNETH
Last Name:DENICOLA
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 PRUDENTIAL DR FL 3
Practice Address - Street 2:UFJP PEDIATRIC CRITICAL CARE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-202-8758
Practice Address - Fax:904-306-9884
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40505208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000252458DMedicaid
FL810000707OtherRAILROAD MEDICARE
FL0669610-00Medicaid
FL810000707OtherRAILROAD MEDICARE
GA000252458DMedicaid