Provider Demographics
NPI:1811915747
Name:COLLUCCI, NICKOLAS JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:JOHN
Last Name:COLLUCCI
Suffix:
Gender:M
Credentials:DO
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 279
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-0279
Mailing Address - Country:US
Mailing Address - Phone:386-586-5344
Mailing Address - Fax:386-586-5450
Practice Address - Street 1:21 HOSPITAL DR
Practice Address - Street 2:SUITE 260
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2452
Practice Address - Country:US
Practice Address - Phone:386-586-5344
Practice Address - Fax:386-586-5450
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4153207Q00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF25834Medicare UPIN
FL82357Medicare ID - Type Unspecified