Provider Demographics
NPI:1104875160
Name:TOMASIC, NICKOLAS ALBERT (MD)
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:ALBERT
Last Name:TOMASIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3831 HUGHES AVE STE 606
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6849
Mailing Address - Country:US
Mailing Address - Phone:310-425-8060
Mailing Address - Fax:104-258-2603
Practice Address - Street 1:3831 HUGHES AVE STE 606
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-6849
Practice Address - Country:US
Practice Address - Phone:310-425-8060
Practice Address - Fax:310-425-8260
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66614208800000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G666140Medicaid
CAWG66614AMedicare PIN
CA00G666140Medicaid
CAW10032Medicare PIN