Provider Demographics
NPI:1306999503
Name:NICHOLAS R. NIKOLOV, M.D.
Entity type:Organization
Organization Name:NICHOLAS R. NIKOLOV, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:NIKOLOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-247-1932
Mailing Address - Street 1:436 N BEDFORD DR
Mailing Address - Street 2:STE 207
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4310
Mailing Address - Country:US
Mailing Address - Phone:310-247-1932
Mailing Address - Fax:310-247-8140
Practice Address - Street 1:436 N BEDFORD DR
Practice Address - Street 2:#207
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4310
Practice Address - Country:US
Practice Address - Phone:310-247-1932
Practice Address - Fax:310-247-8140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78745208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG78745Medicare ID - Type Unspecified