Provider Demographics
NPI:1588856215
Name:PETER NICOLAZZO, M.D., INC
Entity Type:Organization
Organization Name:PETER NICOLAZZO, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-888-7815
Mailing Address - Street 1:PO BOX 7001
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-7001
Mailing Address - Country:US
Mailing Address - Phone:818-888-7815
Mailing Address - Fax:818-715-1722
Practice Address - Street 1:24355 LYONS AVE
Practice Address - Street 2:STE.# 120
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91321-2300
Practice Address - Country:US
Practice Address - Phone:661-255-6644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76738207L00000X
CAG76738A207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G767380OtherMEDI-CAL /EDS
CAG76738AOtherMEDICARE SO CAL.
CA00G767380OtherBLUE SHIELD OF CA
CA273481700OtherUS DEPT OF LABOR
CA273481700OtherUS DEPT OF LABOR