Healthcare Provider Details

I. General information

NPI: 1639191000
Provider Name (Legal Business Name): NICOLAS C PINEDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N CALDWELL ST
STAUNTON IL
62088-1423
US

IV. Provider business mailing address

400 N CALDWELL ST
STAUNTON IL
62088-1423
US

V. Phone/Fax

Practice location:
  • Phone: 618-635-4267
  • Fax: 618-635-4244
Mailing address:
  • Phone: 618-635-4267
  • Fax: 618-635-4244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: