Provider Demographics
NPI:1487727921
Name:THOMAS NICOTRI JR MD LLC
Entity type:Organization
Organization Name:THOMAS NICOTRI JR MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOTRI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:985-626-6996
Mailing Address - Street 1:PO BOX 1536
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-1536
Mailing Address - Country:US
Mailing Address - Phone:985-662-6699
Mailing Address - Fax:985-626-6995
Practice Address - Street 1:1305 W CAUSEWAY APPROACH STE 209
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3043
Practice Address - Country:US
Practice Address - Phone:985-626-6996
Practice Address - Fax:985-626-6995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023801207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1485268Medicaid
LA5BC21Medicare PIN