Basic Information
| Provider Information | |||||||||
| NPI: | 1588856215 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETER NICOLAZZO, M.D., INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7001 | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913577001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887815 | ||||||||
| FaxNumber: | 8187151722 | ||||||||
| Practice Location | |||||||||
| Address1: | 24355 LYONS AVE | ||||||||
| Address2: | STE.# 120 | ||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913212300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612556644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 08/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | NICOLAZZO | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8188887815 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | G76738A | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | G76738 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G767380 | 01 | CA | MEDI-CAL /EDS | OTHER | G76738A | 01 | CA | MEDICARE SO CAL. | OTHER | 00G767380 | 01 | CA | BLUE SHIELD OF CA | OTHER | 273481700 | 01 | CA | US DEPT OF LABOR | OTHER |