Provider Demographics
NPI:1104875160
Name:TOMASIC, NICKOLAS ALBERT (MD)
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:ALBERT
Last Name:TOMASIC
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8540 S SEPULVEDA BLVD
Mailing Address - Street 2:# 911
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3807
Mailing Address - Country:US
Mailing Address - Phone:310-670-9119
Mailing Address - Fax:310-670-7282
Practice Address - Street 1:8540 S SEPULVEDA BLVD
Practice Address - Street 2:# 911
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3807
Practice Address - Country:US
Practice Address - Phone:310-670-9119
Practice Address - Fax:310-670-7282
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66614174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G666140Medicaid
CAWG66614AMedicare PIN
CA00G666140Medicaid
CAW10032Medicare PIN