Healthcare Provider Details

I. General information

NPI: 1457331381
Provider Name (Legal Business Name): NICANOR P SAN NICOLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 STERN RD
SEAMAN OH
45679-9607
US

IV. Provider business mailing address

424 WARDS CORNER RD STE 200
LOVELAND OH
45140-6966
US

V. Phone/Fax

Practice location:
  • Phone: 937-386-1379
  • Fax: 937-386-0129
Mailing address:
  • Phone: 513-707-4041
  • Fax: 513-576-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35079956
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: