Provider Demographics
NPI:1104957554
Name:NISHIDA, GREGORY PAUL (DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:PAUL
Last Name:NISHIDA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20250 SW ACACIA ST
Mailing Address - Street 2:SUITE #150
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1735
Mailing Address - Country:US
Mailing Address - Phone:949-851-2225
Mailing Address - Fax:949-851-2281
Practice Address - Street 1:20250 SW ACACIA ST
Practice Address - Street 2:SUITE #150
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1735
Practice Address - Country:US
Practice Address - Phone:949-851-2225
Practice Address - Fax:949-851-2281
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20722111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU01157Medicare UPIN
CADC20722Medicare ID - Type Unspecified