Provider Demographics
NPI:1124178900
Name:PUTNAM, NICHOLAS HERKIMER (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:HERKIMER
Last Name:PUTNAM
Suffix:
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 1:4401 MANCHESTER AVE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-4938
Mailing Address - Country:US
Mailing Address - Phone:760-753-4564
Mailing Address - Fax:760-753-1541
Practice Address - Street 1:4401 MANCHESTER AVE
Practice Address - Street 2:SUITE #101
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-4938
Practice Address - Country:US
Practice Address - Phone:760-753-4564
Practice Address - Fax:760-753-1541
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG275622084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG0027562Medicaid
CAA43399Medicare UPIN