Provider Demographics
NPI:1952583395
Name:ACQUAVELLA PESANTES, NICOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:ACQUAVELLA PESANTES
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 1:1120 NW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-2107
Mailing Address - Country:US
Mailing Address - Phone:305-243-4860
Mailing Address - Fax:
Practice Address - Street 1:1120 NW 14TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-2107
Practice Address - Country:US
Practice Address - Phone:305-243-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME121553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program