Provider Demographics
NPI:1457331381
Name:SAN NICOLAS, NICANOR P (MD)
Entity Type:Individual
Prefix:
First Name:NICANOR
Middle Name:P
Last Name:SAN NICOLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 WARDS CORNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-6966
Mailing Address - Country:US
Mailing Address - Phone:513-707-4041
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:218 STERN RD
Practice Address - Street 2:
Practice Address - City:SEAMAN
Practice Address - State:OH
Practice Address - Zip Code:45679-9607
Practice Address - Country:US
Practice Address - Phone:937-386-1379
Practice Address - Fax:937-386-0129
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079956208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2260708Medicaid
OHNI2022003Medicare PIN
OHNI2022001Medicare PIN
OHNI2022002Medicare PIN
OHH47427Medicare UPIN