1750355657 NPI number — CLINTON R NICHOLS MD

Table of content: CLINTON R NICHOLS MD (NPI 1750355657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750355657 NPI number — CLINTON R NICHOLS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
CLINTON
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750355657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23540
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92193-3540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-565-0950
Provider Business Mailing Address Fax Number:
858-244-1100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8745 AERO DRIVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-1774
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-565-0950
Provider Business Practice Location Address Fax Number:
858-244-1100
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X , with the licence number: A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085B0100X , with the licence number: A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X , with the licence number: A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X , with the licence number: A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X , with the licence number: A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085P0229X , with the licence number: A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0203X , with the licence number: A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: A71406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0083816 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: TD009B , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0083817 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0083812 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0083815 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0083813 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR083810 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0083811 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0083814 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ75341Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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