Provider Demographics
NPI:1174674436
Name:SURDOCK, NICOLE MARIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:SURDOCK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 PEBBLE BEACH CT
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-5724
Mailing Address - Country:US
Mailing Address - Phone:510-435-8472
Mailing Address - Fax:
Practice Address - Street 1:47 PENNY LN
Practice Address - Street 2:SUITE 1
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6055
Practice Address - Country:US
Practice Address - Phone:831-728-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4802213EP1101X
CAEL 1671213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEL 1671OtherD.P.M. RESIDENT'S LICENSE
CAE 4802OtherCALIFORNIA STATE LICENSE- DOCOTR OF PODIATRIC MEDICINE AND ANKLE SURGERY