Provider Demographics
NPI:1710058987
Name:TEOPHILOV, NICKOLAY T (MD)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAY
Middle Name:T
Last Name:TEOPHILOV
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 1:2385 ROSCOMARE RD
Mailing Address - Street 2:B-8
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 W EULALIA ST
Practice Address - Street 2:SUITE 301
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2849
Practice Address - Country:US
Practice Address - Phone:310-472-0171
Practice Address - Fax:310-472-0171
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55038207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A550380Medicaid
CA00A550380Medicaid
CAB50513Medicare UPIN