Basic Information
| Provider Information | |||||||||
| NPI: | 1356359277 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | NICIFOROS | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 TOWNE CENTER DR | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093981550 | ||||||||
| FaxNumber: | 9093981488 | ||||||||
| Practice Location | |||||||||
| Address1: | 9190 HAVEN AVE | ||||||||
| Address2: | SUITE # 102 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917305431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095278110 | ||||||||
| FaxNumber: | 9095816738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | C26175 | CA | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | C26175 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.