Provider Demographics
NPI:1194753335
Name:NICOTRA, JOHN J (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:NICOTRA
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 46100
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-0100
Mailing Address - Country:US
Mailing Address - Phone:763-553-9920
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:612-813-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN425492085P0229X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG28885Medicare UPIN