Provider Demographics
NPI:1861594731
Name:NIKLAS, VICTORIA NINON OLIVIA (MD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:NINON OLIVIA
Last Name:NIKLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:SMITH, CAMERINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:407-650-7129
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1717 S. ORANGE AVE., SUITE 100
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC, ORLANDO
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2946
Practice Address - Country:US
Practice Address - Phone:407-650-7715
Practice Address - Fax:407-650-7124
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG705262080N0001X
FLME1137262080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G705260Medicaid
CAWG70526CMedicare ID - Type Unspecified
CA00G705260Medicaid