Basic Information
Provider Information
NPI: 1033211685
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NICHOLAS
FirstName: JULIAN
MiddleName: J.
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7891 PIPIT PL
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921294532
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 2400 S AVENUE A
Address2:  
City: YUMA
State: AZ
PostalCode: 853647170
CountryCode: US
TelephoneNumber: 9283442000
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/03/2006
LastUpdateDate: 03/31/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/31/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RG0100XA72818CAY Allopathic & Osteopathic PhysiciansInternal MedicineGastroenterology

ID Information
IDTypeStateIssuerDescription
00A72818005CA MEDICAID
11021817801 RAILROAD MEDICAREOTHER
B17901 CHAMPUSOTHER
F67501 CHAMPUSOTHER


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