Healthcare Provider Details

I. General information

NPI: 1831696194
Provider Name (Legal Business Name): NICHOLUS MICHAEL WARSTADT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4077 FIFTH AVE
SAN DIEGO CA
92103-2105
US

IV. Provider business mailing address

4077 FIFTH AVE
SAN DIEGO CA
92103-2105
US

V. Phone/Fax

Practice location:
  • Phone: 619-686-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA175155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: