Provider Demographics
NPI:1932239837
Name:DZEBOLO, NICHOLAS N (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:N
Last Name:DZEBOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1100 RIDGESIDE DR
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-3731
Mailing Address - Country:US
Mailing Address - Phone:626-281-6442
Mailing Address - Fax:888-302-2447
Practice Address - Street 1:2105 BEVERLY BLVD STE 111
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2252
Practice Address - Country:US
Practice Address - Phone:213-484-3994
Practice Address - Fax:212-484-8795
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0363962085N0904X, 2085R0202X, 2085R0204X, 207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A46671Medicare UPIN