Basic Information
| Provider Information | |||||||||
| NPI: | 1912132432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOSIA KURIAN | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 BROADWAY DEPARTMENT OF MANAGED CARE ROOM 2B230 | ||||||||
| Address2: | WOODHULL MEDICAL & MENTAL HEALTH CENTER | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
| FaxNumber: | 7186303122 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 BROADWAY | ||||||||
| Address2: | WOODHULL MEDICAL & MENTAL HEALTH CENTER | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2009 | ||||||||
| LastUpdateDate: | 07/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 275974 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207VG0400X | MD60356687 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 275974 | 01 | NY | MEDICAL LICENSE | OTHER | 1912132432 | 05 | WA | MEDICAID |