Provider Demographics
NPI:1689844672
Name:ROY D NINI MD INC
Entity Type:Organization
Organization Name:ROY D NINI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:D
Authorized Official - Last Name:NINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-441-4700
Mailing Address - Street 1:122 SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3915
Mailing Address - Country:US
Mailing Address - Phone:310-322-4278
Mailing Address - Fax:
Practice Address - Street 1:1440 N HARBOR BLVD
Practice Address - Street 2:SUITE #100
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4127
Practice Address - Country:US
Practice Address - Phone:310-423-9885
Practice Address - Fax:310-423-9819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA798982081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW22188Medicare PIN
CA6621010001Medicare NSC