Provider Demographics
NPI:1699956789
Name:DI NICOLO, ROBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name:DI NICOLO
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 1:353 N CLYDE MORRIS BLVD
Mailing Address - Street 2:SUTE 1
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2732
Mailing Address - Country:US
Mailing Address - Phone:386-252-6622
Mailing Address - Fax:
Practice Address - Street 1:353 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUTE 1
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2732
Practice Address - Country:US
Practice Address - Phone:386-252-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051694207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E95703Medicare UPIN
12783Medicare PIN