Provider Demographics
NPI:1720121833
Name:NICOSIA, ROGER GUY (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:GUY
Last Name:NICOSIA
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 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-782-5110
Mailing Address - Fax:951-274-0403
Practice Address - Street 1:7160 BROCKTON AVE.
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3912
Practice Address - Country:US
Practice Address - Phone:951-782-3801
Practice Address - Fax:951-328-9742
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32221207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A322210Medicaid
CA1730180415OtherGROUP NPI
CA00A322210Medicare ID - Type Unspecified