Provider Demographics
NPI:1336186121
Name:NIDORF, DAVID MARK (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MARK
Last Name:NIDORF
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 1:384 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1529
Mailing Address - Country:US
Mailing Address - Phone:415-453-5717
Mailing Address - Fax:
Practice Address - Street 1:3555 CESAR CHAVEZ
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4403
Practice Address - Country:US
Practice Address - Phone:415-641-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49983207P00000X, 207Q00000X
NY251090207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A499830Medicaid
CAAN610YMedicare PIN
CA00A499833Medicare PIN
CA00A499839Medicare PIN
CA00A499830Medicare PIN
CA00A499835Medicare PIN
CA00A499830Medicaid
CA00A499838Medicare PIN
CA00A4998310Medicare PIN
CAAN610ZMedicare PIN