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General NPI Number Information
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NPI Number | 1396185161
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Entity Type | Individual
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Provider Name | NICHOLAS KUSNEZOV M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/26/2013
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Last Update Date | 05/02/2025
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Provider Practice Location Address
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Address Line | 5643 COPLEY DR STE 300
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City | SAN DIEGO
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State | CA
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Zip | 92111-7903
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Country | US
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Telephone | 858-455-9942
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Fax | 858-455-6473
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Provider Business Mailing Address
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Address Line | 5643 COPLEY DR STE 300
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City | SAN DIEGO
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State | CA
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Zip | 92111-7903
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Country | US
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Telephone | 858-455-9942
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Fax | 858-455-6473
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 036147531
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 51891
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License Number State | KY
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Taxonomy #3
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 58084
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License Number State | AZ
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Taxonomy #4
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | A155908
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License Number State | CA
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