Provider Demographics
NPI:1992876155
Name:MARSICO, NICHOLAS P (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:P
Last Name:MARSICO
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 1:420 E 3RD ST
Mailing Address - Street 2:SUITE 603
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1644
Mailing Address - Country:US
Mailing Address - Phone:213-680-1551
Mailing Address - Fax:213-680-2148
Practice Address - Street 1:420 E 3RD ST
Practice Address - Street 2:SUITE 603
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1644
Practice Address - Country:US
Practice Address - Phone:213-680-1551
Practice Address - Fax:213-680-2148
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86442174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078580Medicaid
CAGR0078583Medicaid
CAGR0078582Medicaid
CA00A864420Medicaid
CA1710057245OtherGROUP NPI
CAGR0078581Medicaid
CA00A864420Medicaid
CA1176620004Medicare NSC
CA1176620001Medicare NSC
CAW13961AMedicare ID - Type UnspecifiedGROUP NUMBER
H38680Medicare UPIN
CAWA86442DMedicare ID - Type UnspecifiedINDIVIDUAL
CAWA86442AMedicare ID - Type UnspecifiedINDIVIDUAL
CAGR0078581Medicaid
CA1176620003Medicare NSC
CAW13961CMedicare ID - Type UnspecifiedGROUP NUMBER
CAGR0078582Medicaid
CAGR0078583Medicaid
CA1176620002Medicare NSC