Basic Information
Provider Information | |||||||||
NPI: | 1750355657 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICHOLS | ||||||||
FirstName: | CLINTON | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23540 | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921933540 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585650950 | ||||||||
FaxNumber: | 8582441100 | ||||||||
Practice Location | |||||||||
Address1: | 8745 AERO DRIVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921231774 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585650950 | ||||||||
FaxNumber: | 8582441100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2006 | ||||||||
LastUpdateDate: | 10/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A71406 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | A71406 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085B0100X | A71406 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085U0001X | A71406 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085N0700X | A71406 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | A71406 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | A71406 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0203X | A71406 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 208VP0014X | A71406 | CA | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208VP0000X | A71406 | CA | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | GR0083816 | 05 | CA |   | MEDICAID | TD009B | 05 | CA |   | MEDICAID | GR0083817 | 05 | CA |   | MEDICAID | GR0083812 | 05 | CA |   | MEDICAID | GR0083815 | 05 | CA |   | MEDICAID | GR0083813 | 05 | CA |   | MEDICAID | GR083810 | 05 | CA |   | MEDICAID | GR0083811 | 05 | CA |   | MEDICAID | GR0083814 | 05 | CA |   | MEDICAID | ZZZ75341Z | 05 | CA |   | MEDICAID |