Provider Demographics
NPI:1669421293
Name:SOUTHALL, NIKKITA F (MD)
Entity type:Individual
Prefix:DR
First Name:NIKKITA
Middle Name:F
Last Name:SOUTHALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NIKKITA
Other - Middle Name:F
Other - Last Name:PESSOA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-5756
Mailing Address - Fax:410-328-0267
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-5756
Practice Address - Fax:410-328-0267
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD63236207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4103521-00Medicaid
MD647060-01OtherBLUE CROSS/BLUE SHIELD
MD4103521-00Medicaid
MDO022Medicare PIN
MDP00370203Medicare PIN