Basic Information
Provider Information | |||||||||
NPI: | 1184736480 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICOLA | ||||||||
FirstName: | FREDERIC | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M. D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13160 MINDANAO WAY | ||||||||
Address2: | STE 300 | ||||||||
City: | MARINA DEL REY | ||||||||
State: | CA | ||||||||
PostalCode: | 902926358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3105740400 | ||||||||
FaxNumber: | 3105740485 | ||||||||
Practice Location | |||||||||
Address1: | 13160 MINDANAO WAY | ||||||||
Address2: | STE 300 | ||||||||
City: | MARINA DEL REY | ||||||||
State: | CA | ||||||||
PostalCode: | 902926358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3105740400 | ||||||||
FaxNumber: | 3105740485 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 04/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G38262 | CA | Y |   | Other Service Providers | Specialist |   | 207X00000X | G38262 | CA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0005X | G38262 | CA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0801X | G38262 | CA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207XX0004X | G38262 | CA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 953951031 | 01 | CA | TAX ID | OTHER |