Provider Demographics
NPI:1063596831
Name:NICOLOSI, CHARLES R (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:NICOLOSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:R
Other - Last Name:NICOLOSI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2031 32ND ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7099
Mailing Address - Country:US
Mailing Address - Phone:608-788-8103
Mailing Address - Fax:
Practice Address - Street 1:116 MILL ST W.
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009-2027
Practice Address - Country:US
Practice Address - Phone:608-788-8103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20585174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN127T7NIOtherBCBS MN
MND91458Medicare UPIN