Provider Demographics
NPI:1083026397
Name:NICODEMUS MEDICAL CORPORATION
Entity type:Organization
Organization Name:NICODEMUS MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:NICODEMUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO PHD
Authorized Official - Phone:831-644-9614
Mailing Address - Street 1:910 MAJOR SHERMAN LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-4642
Mailing Address - Country:US
Mailing Address - Phone:831-664-9614
Mailing Address - Fax:831-644-9615
Practice Address - Street 1:910 MAJOR SHERMAN LN
Practice Address - Street 2:SUITE 300
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-4642
Practice Address - Country:US
Practice Address - Phone:831-664-9614
Practice Address - Fax:831-644-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10296204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAQ237Medicare PIN