Healthcare Provider Details

I. General information

NPI: 1003890666
Provider Name (Legal Business Name): ALPHONSO NICHOLS III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9750 MIRAMAR RD STE 200
SAN DIEGO CA
92126-4562
US

IV. Provider business mailing address

10755 SCRIPPS POWAY PKWY # 455
SAN DIEGO CA
92131-3924
US

V. Phone/Fax

Practice location:
  • Phone: 858-412-7362
  • Fax: 858-368-9797
Mailing address:
  • Phone: 858-412-7362
  • Fax: 858-368-9797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC177109
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number39438
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number01061506A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC177109
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: