Provider Demographics
NPI:1083954051
Name:NICOLAS, SAMUEL ALVIN IV (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ALVIN
Last Name:NICOLAS
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:619-532-6210
Mailing Address - Fax:619-532-5477
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-6210
Practice Address - Fax:619-532-5477
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1322102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry