Provider Demographics
NPI:1689019424
Name:CASELMAN, NICHOLAS C
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:C
Last Name:CASELMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:323-226-7556
Mailing Address - Fax:323-226-2657
Practice Address - Street 1:2010 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1026
Practice Address - Country:US
Practice Address - Phone:323-409-5086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA135366207R00000X, 208000000X
MO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3232267556OtherLAC USC