Basic Information
Provider Information | |||||||||
NPI: | 1235500422 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORETTI | ||||||||
FirstName: | NICHOLAS | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15773 NW 3RD ST | ||||||||
Address2: |   | ||||||||
City: | PEMBROKE PINES | ||||||||
State: | FL | ||||||||
PostalCode: | 330281588 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3057126395 | ||||||||
FaxNumber: | 3056308590 | ||||||||
Practice Location | |||||||||
Address1: | 2951 NW 49TH AVE STE 201 | ||||||||
Address2: |   | ||||||||
City: | LAUDERDALE LAKES | ||||||||
State: | FL | ||||||||
PostalCode: | 333131608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9544865700 | ||||||||
FaxNumber: | 9544842574 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2015 | ||||||||
LastUpdateDate: | 06/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO3838 | FL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.