Individual
CARLO G NICOLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
200 STATE STREET, SUITE 205, MEDIA, PA 19063-3434
(610) 521-4112
(610) 521-6864
Mailing address
PO BOX 95000-3505, PHILA, PA 19195-0001
(610) 382-5900
(610) 382-5918
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MD432640
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
MD432640
LIC NUMBER
PA
Enumeration date
06/23/2006
Last updated
03/07/2023
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