Healthcare Provider Details

I. General information

NPI: 1205138328
Provider Name (Legal Business Name): NICK DZEBOLO MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 S GLENDALE AVE SUITE 200
GLENDALE CA
91205-2866
US

IV. Provider business mailing address

1030 S GLENDALE AVE SUITE 200
GLENDALE CA
91205-2866
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-5072
  • Fax: 818-244-1768
Mailing address:
  • Phone: 818-241-5072
  • Fax: 818-244-1768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS N DZEBOLO
Title or Position: CEO
Credential: MD
Phone: 818-241-5072