Provider Demographics
NPI:1386723229
Name:NICOLAS, JOSEPH JEAN (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JEAN
Last Name:NICOLAS
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 1:1952 MIDLANE S
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-9606
Mailing Address - Country:US
Mailing Address - Phone:516-921-2794
Mailing Address - Fax:
Practice Address - Street 1:10415 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-2032
Practice Address - Country:US
Practice Address - Phone:718-776-6050
Practice Address - Fax:718-776-6051
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2016-10-05
Deactivation Date:2016-09-27
Deactivation Code:
Reactivation Date:2016-10-05
Provider Licenses
StateLicense IDTaxonomies
NY130265207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00443210Medicaid
NY99861Medicare ID - Type Unspecified
NY00443210Medicaid