Provider Demographics
NPI:1255642179
Name:WADIWALA, NICKY MAHBOOB (DO)
Entity type:Individual
Prefix:DR
First Name:NICKY
Middle Name:MAHBOOB
Last Name:WADIWALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 E CESAR E CHAVEZ AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2467
Mailing Address - Country:US
Mailing Address - Phone:323-268-2200
Mailing Address - Fax:323-268-2212
Practice Address - Street 1:1700 E CESAR E CHAVEZ AVE STE 1200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2467
Practice Address - Country:US
Practice Address - Phone:323-268-2200
Practice Address - Fax:323-268-2200
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11280207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0082854Medicaid
OHH198010OtherMEDICARE PTAN