Provider Demographics
NPI:1417903337
Name:GUNASAYAN, NICK LADDHAPHOL (DPM)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:LADDHAPHOL
Last Name:GUNASAYAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:LADDHAPHOL
Other - Middle Name:NICK
Other - Last Name:GUNASAYAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93483-0759
Mailing Address - Country:US
Mailing Address - Phone:805-712-6867
Mailing Address - Fax:888-851-4755
Practice Address - Street 1:862 MEINECKE AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-3703
Practice Address - Country:US
Practice Address - Phone:805-540-5770
Practice Address - Fax:888-851-4755
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4414213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4414OtherSTATE LICENSE
42-1710674OtherEIN
CAE4414OtherSTATE LICENSE