MEDICARE: FREDERIC G NICOLA M. D.

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	174400000X	Specialist	G38262	CA
2	207X00000X	Orthopaedic Surgery Physician	G38262	CA
3	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	G38262	CA
4	207XX0801X	Orthopaedic Trauma Physician	G38262	CA
5	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician	G38262	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	953951031	OTHER	CA	TAX ID

General Provider Information

NPI Number	:	1184736480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERIC G NICOLA M. D.

Provider Business Mailing Address
First Line	:	13160 MINDANAO WAY
Second Line	:	STE 300
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-6358
Country	:	US
Telephone Number	:	310-574-0400
Fax Number	:	310-574-0485

Provider Business Practice Location Address
First Line	:	13160 MINDANAO WAY
Second Line	:	STE 300
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-6358
Country	:	US
Telephone Number	:	310-574-0400
Fax Number	:	310-574-0485

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	04/14/2011

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Directions to “ FREDERIC G NICOLA M. D.” Practice Location

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