Provider Demographics
NPI:1427145218
Name:NICHOLS, STEPHEN P (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:P
Last Name:NICHOLS
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 1:351 SANTA FE DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024
Mailing Address - Country:US
Mailing Address - Phone:760-633-3130
Mailing Address - Fax:760-633-3546
Practice Address - Street 1:351 SANTA FE DR.
Practice Address - Street 2:SUITE 100
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024
Practice Address - Country:US
Practice Address - Phone:760-633-3130
Practice Address - Fax:760-633-3546
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57814207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G578140OtherBLUE SHIELD
CAW19338Medicare ID - Type Unspecified
CA00G578140OtherBLUE SHIELD