Provider Demographics
NPI:1982808622
Name:ST NICHOLAS MEDICAL GROUP
Entity Type:Organization
Organization Name:ST NICHOLAS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:ESGUERRA
Authorized Official - Last Name:TIZON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-860-9054
Mailing Address - Street 1:5520 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038
Mailing Address - Country:US
Mailing Address - Phone:323-860-9054
Mailing Address - Fax:323-860-9053
Practice Address - Street 1:5520 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-2932
Practice Address - Country:US
Practice Address - Phone:323-860-9054
Practice Address - Fax:323-860-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21726Medicare PIN