Individual
EILEEN NIKKO SUPER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
3601 SW 160TH AVE, SUITE 250, MIRAMAR, FL 33027-6308
(877) 866-7123
(855) 855-2792
Mailing address
936 BROAD ST, UNIT 303, AUGUSTA, GA 30901-8200
(801) 916-1782
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
74602
GA
208600000X
Surgery Physician
Primary
74602
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
74602
GEORGIA COMPOSITE MEDICAL BOARD
GA
Enumeration date
06/02/2013
Last updated
08/26/2016
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