Provider Demographics
NPI:1265507248
Name:PACIFIC ORTHOPAEDICS & SPORTS MEDICINE
Entity Type:Organization
Organization Name:PACIFIC ORTHOPAEDICS & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-633-3130
Mailing Address - Street 1:PO BOX 1240
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-7240
Mailing Address - Country:US
Mailing Address - Phone:760-633-3130
Mailing Address - Fax:760-633-3546
Practice Address - Street 1:351 SANTA FE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5137
Practice Address - Country:US
Practice Address - Phone:760-633-3130
Practice Address - Fax:760-633-3546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ62507ZOtherBLUE SHIELD
CAW21034Medicare PIN
CAZZZ62507ZOtherBLUE SHIELD