Provider Demographics
NPI:1437656923
Name:GENERALES, NICHOLAS (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GENERALES
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 1:807 N KEMP ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-2720
Mailing Address - Country:US
Mailing Address - Phone:818-426-6864
Mailing Address - Fax:
Practice Address - Street 1:4849 VAN NUYS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2115
Practice Address - Country:US
Practice Address - Phone:818-646-4928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A19090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine