Provider Demographics
NPI:1164491478
Name:SCAVO, NICKOLAS ANTHONY (OD)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:ANTHONY
Last Name:SCAVO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24673 LAS PATRANAS
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-5114
Mailing Address - Country:US
Mailing Address - Phone:714-692-2631
Mailing Address - Fax:714-692-5716
Practice Address - Street 1:900 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-3025
Practice Address - Country:US
Practice Address - Phone:714-525-9003
Practice Address - Fax:714-525-8206
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 8023 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT 8023 TPAOtherOPTOMETRY LICENSE NUMBER