Provider Demographics
NPI:1669478400
Name:GARCIA, NICODEMUS J (MD)
Entity Type:Individual
Prefix:
First Name:NICODEMUS
Middle Name:J
Last Name:GARCIA
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 1:4550 KEARNY VILLA RD
Mailing Address - Street 2:STE. 116
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1578
Mailing Address - Country:US
Mailing Address - Phone:858-279-1223
Mailing Address - Fax:858-467-7161
Practice Address - Street 1:4550 KEARNY VILLA RD
Practice Address - Street 2:STE. 116
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1578
Practice Address - Country:US
Practice Address - Phone:858-279-1223
Practice Address - Fax:858-467-7161
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO1046792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS206935827Medicaid
MS206935827Medicaid
MOF83593Medicare UPIN