Healthcare Provider Details

I. General information

NPI: 1457574816
Provider Name (Legal Business Name): DR. THEODORE PAUL NICOLAIDES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE M649, BOX 0106
SAN FRANCISCO CA
94143-2204
US

IV. Provider business mailing address

1738 HAIGHT ST APT 204
SAN FRANCISCO CA
94117-2866
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-3831
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberA87645
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: