Provider Demographics
NPI:1720127921
Name:ANDONOV, NICK B (PHD)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:B
Last Name:ANDONOV
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 N SIERRA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3546
Mailing Address - Country:US
Mailing Address - Phone:909-883-5977
Mailing Address - Fax:909-881-4070
Practice Address - Street 1:2380 N SIERRA WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3546
Practice Address - Country:US
Practice Address - Phone:909-883-5977
Practice Address - Fax:909-881-4070
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4792103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL47920Medicaid
CA00PL47920Medicaid
R26051Medicare UPIN