Healthcare Provider Details

I. General information

NPI: 1265762090
Provider Name (Legal Business Name): NICHOLAS J BEVILACQUA D P M INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15107 VANOWEN ST
VAN NUYS CA
91405-4542
US

IV. Provider business mailing address

15107 VANOWEN ST
VAN NUYS CA
91405-4542
US

V. Phone/Fax

Practice location:
  • Phone: 818-902-5755
  • Fax: 818-902-5766
Mailing address:
  • Phone: 818-902-5755
  • Fax: 818-902-5766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4859
License Number StateCA

VIII. Authorized Official

Name: DR. NICHOLAS J BEVILACQUA
Title or Position: OWNER
Credential: D.P.M.
Phone: 818-902-5755