Provider Demographics
NPI:1427132000
Name:NICK L. GUNASAYAN, D.P.M., INC.
Entity type:Organization
Organization Name:NICK L. GUNASAYAN, D.P.M., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNASAYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-712-6867
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93483-0759
Mailing Address - Country:US
Mailing Address - Phone:805-712-6867
Mailing Address - Fax:888-851-4755
Practice Address - Street 1:862 MEINECKE AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-3703
Practice Address - Country:US
Practice Address - Phone:805-540-5770
Practice Address - Fax:888-851-4755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4414213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4414OtherCALIFORNIA LICENSE
CAW20386Medicare PIN
CA5797150001Medicare NSC
CAE4414OtherCALIFORNIA LICENSE
CA5797150002Medicare NSC