Healthcare Provider Details

I. General information

NPI: 1578956249
Provider Name (Legal Business Name): GREGG K. NISHI, MD, A CALIFORNIA PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9033 WILSHIRE BLVD SUITE 200
BEVERLY HILLS CA
90211-1837
US

IV. Provider business mailing address

9033 WILSHIRE BLVD SUITE 200
BEVERLY HILLS CA
90211-1837
US

V. Phone/Fax

Practice location:
  • Phone: 310-858-1242
  • Fax: 310-858-1172
Mailing address:
  • Phone: 310-858-1242
  • Fax: 310-858-1172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA75418
License Number StateCA

VIII. Authorized Official

Name: DR. GREGG KAIZO NISHI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-858-1242