Provider Demographics
NPI:1306052246
Name:LACZ, NICOLE LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LYNN
Last Name:LACZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 PASSAIC AVE
Mailing Address - Street 2:STE 360
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1800
Mailing Address - Country:US
Mailing Address - Phone:973-284-0020
Mailing Address - Fax:973-284-6310
Practice Address - Street 1:20 HIGH ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1132
Practice Address - Country:US
Practice Address - Phone:973-879-3964
Practice Address - Fax:973-284-0269
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA087935002085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ527286Medicare PIN