Provider Demographics
NPI:1659364933
Name:ANTON, NICHOLAS HARRELD (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:HARRELD
Last Name:ANTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-544-3411
Mailing Address - Fax:707-544-0834
Practice Address - Street 1:500 DOYLE PARK DR
Practice Address - Street 2:STE G03
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4559
Practice Address - Country:US
Practice Address - Phone:707-544-3411
Practice Address - Fax:707-544-0834
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC36268207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00C362680OtherBLUE SHIELD OF CALIFORNIA
P00410327OtherRAILROAD MEDICARE
CA00C362680Medicaid
CA00C362682Medicare PIN
CA00C362680Medicaid