Healthcare Provider Details

I. General information

NPI: 1124178900
Provider Name (Legal Business Name): NICHOLAS HERKIMER PUTNAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 MANCHESTER AVE SUITE #101
ENCINITAS CA
92024-4938
US

IV. Provider business mailing address

4401 MANCHESTER AVE SUITE #101
ENCINITAS CA
92024-4938
US

V. Phone/Fax

Practice location:
  • Phone: 760-753-4564
  • Fax: 760-753-1541
Mailing address:
  • Phone: 760-753-4564
  • Fax: 760-753-1541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG27562
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG27562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: