MEDICARE: NICOLE LAUREN DEPOLO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	D0103262	MD

General Provider Information

NPI Number	:	1164080636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LAUREN DEPOLO MD

Provider Business Mailing Address
First Line	:	6201 GREENLEIGH AVE FL 2
Second Line	:
City	:	MIDDLE RIVER
State	:	MD
Zip	:	21220-2004
Country	:	US
Telephone Number	:	410-933-0000
Fax Number	:	410-500-4266

Provider Business Practice Location Address
First Line	:	11234 ANDERSON ST
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-2804
Country	:	US
Telephone Number	:	909-558-2822
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2019
Last Update Date	:	05/09/2026

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