1164491478 NPI number — DR. NICKOLAS ANTHONY SCAVO O.D.

Table of content: DR. NICKOLAS ANTHONY SCAVO O.D. (NPI 1164491478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164491478 NPI number — DR. NICKOLAS ANTHONY SCAVO O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCAVO
Provider First Name:
NICKOLAS
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164491478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24673 LAS PATRANAS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORBA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92887-5114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-692-2631
Provider Business Mailing Address Fax Number:
714-692-5716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 S HARBOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92832-3025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-525-9003
Provider Business Practice Location Address Fax Number:
714-525-8206
Provider Enumeration Date:
03/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT 8023 TPA , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OPT 8023 TPA . This is a "OPTOMETRY LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com