Provider Demographics
NPI:1851694541
Name:NISSENBAUM, SCOTT DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DAVID
Last Name:NISSENBAUM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAUREL ST STE D
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-5000
Mailing Address - Country:US
Mailing Address - Phone:415-302-9007
Mailing Address - Fax:650-666-6747
Practice Address - Street 1:1100 LAUREL ST STE D
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-5000
Practice Address - Country:US
Practice Address - Phone:415-302-9007
Practice Address - Fax:650-666-6747
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-31093111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor