Provider Demographics
NPI:1184736480
Name:NICOLA, FREDERIC G (M D)
Entity type:Individual
Prefix:
First Name:FREDERIC
Middle Name:G
Last Name:NICOLA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13160 MINDANAO WAY
Mailing Address - Street 2:STE 300
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6358
Mailing Address - Country:US
Mailing Address - Phone:310-574-0400
Mailing Address - Fax:310-574-0485
Practice Address - Street 1:13160 MINDANAO WAY
Practice Address - Street 2:STE 300
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6358
Practice Address - Country:US
Practice Address - Phone:310-574-0400
Practice Address - Fax:310-574-0485
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38262174400000X, 207X00000X, 207XX0005X, 207XX0801X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953951031OtherTAX ID