Basic Information
| Provider Information | |||||||||
| NPI: | 1275512394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICOLITZ | ||||||||
| FirstName: | ERNST | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043964893 | ||||||||
| Practice Location | |||||||||
| Address1: | 7051 SOUTHPOINT PKWY S STE 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322168713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043982720 | ||||||||
| FaxNumber: | 9043986408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME31869 | FL | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0200X | ME31869 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 15445 | 01 | FL | BCBS-FL | OTHER | Q00069488 | 01 | FL | RAILROAD MEDICARE | OTHER | NS943 | 01 | FL | MEDICARE | OTHER |