Provider Demographics
NPI:1811949902
Name:JOHN K NYLUND MD INC
Entity type:Organization
Organization Name:JOHN K NYLUND MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDI
Authorized Official - Middle Name:V
Authorized Official - Last Name:NYLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-643-9333
Mailing Address - Street 1:14650 AVIATION BLVD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-6656
Mailing Address - Country:US
Mailing Address - Phone:310-643-9333
Mailing Address - Fax:310-643-9337
Practice Address - Street 1:14650 AVIATION BLVD
Practice Address - Street 2:SUITE 235
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-6656
Practice Address - Country:US
Practice Address - Phone:310-643-9333
Practice Address - Fax:310-643-9337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC34111207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A35503Medicare UPIN
CAW9243Medicare ID - Type Unspecified