Provider Demographics
NPI:1609817717
Name:NICHOLS, WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:NICHOLS
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 1:31255 CEDAR VALLEY DR
Mailing Address - Street 2:SUITE 324
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4014
Mailing Address - Country:US
Mailing Address - Phone:818-338-8103
Mailing Address - Fax:818-338-8119
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:ROOM 8725
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-6627
Practice Address - Fax:310-423-0170
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24783174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42387Medicare UPIN