Provider Demographics
NPI:1255677670
Name:MUSSO, NICHOLAS DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DANIEL
Last Name:MUSSO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-1717
Mailing Address - Country:US
Mailing Address - Phone:801-712-6125
Mailing Address - Fax:
Practice Address - Street 1:7707 AUSTIN RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95215
Practice Address - Country:US
Practice Address - Phone:209-467-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A187572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry