Provider Demographics
NPI:1508391533
Name:DIMASSA, NICHOLAS VINCENT (DPM)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:VINCENT
Last Name:DIMASSA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GLENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-1530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:807 FARSON ST STE 204C
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-1069
Practice Address - Country:US
Practice Address - Phone:740-423-3207
Practice Address - Fax:740-423-3227
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003975213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0401406Medicaid