Healthcare Provider Details

I. General information

NPI: 1932239837
Provider Name (Legal Business Name): NICHOLAS N DZEBOLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 BEVERLY BLVD STE 111
LOS ANGELES CA
90057-2252
US

IV. Provider business mailing address

1100 RIDGESIDE DR
MONTEREY PARK CA
91754-3731
US

V. Phone/Fax

Practice location:
  • Phone: 213-484-3994
  • Fax: 212-484-8795
Mailing address:
  • Phone: 626-281-6442
  • Fax: 888-302-2447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberG036396
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG036396
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG036396
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberG036396
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberG036396
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: