Provider Demographics
NPI:1831269018
Name:CHIARADONNA, NICOLA L (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:L
Last Name:CHIARADONNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3480 PRESTON RIDGE RD STE 600
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5462
Mailing Address - Country:US
Mailing Address - Phone:770-300-0101
Mailing Address - Fax:770-300-0429
Practice Address - Street 1:2525 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5071
Practice Address - Country:US
Practice Address - Phone:505-522-6236
Practice Address - Fax:505-522-2157
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ323082085R0202X
MO20060024422085R0202X
NMMD2006-07022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR83801OtherAR BLUE SHIELD #
AR83801OtherAR BLUE SHIELD #