Provider Demographics
NPI:1356359277
Name:NICIFOROS, PETER JOHN (MD)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
Last Name:NICIFOROS
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 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1488
Practice Address - Street 1:9190 HAVEN AVE
Practice Address - Street 2:SUITE # 102
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5431
Practice Address - Country:US
Practice Address - Phone:909-527-8110
Practice Address - Fax:909-581-6738
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC26175208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
A33062Medicare UPIN