Healthcare Provider Details

I. General information

NPI: 1720121833
Provider Name (Legal Business Name): ROGER GUY NICOSIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7160 BROCKTON AVE.
RIVERSIDE CA
92506-3912
US

IV. Provider business mailing address

3660 ARLINGTON AVE
RIVERSIDE CA
92506-3912
US

V. Phone/Fax

Practice location:
  • Phone: 951-782-3801
  • Fax: 951-328-9742
Mailing address:
  • Phone: 951-782-5110
  • Fax: 951-274-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA32221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: