MEDICARE: NICHOLAS KUSNEZOV 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	207X00000X	Orthopaedic Surgery Physician	036147531	IL
2	207X00000X	Orthopaedic Surgery Physician	51891	KY
3	207X00000X	Orthopaedic Surgery Physician	58084	AZ
4	207X00000X	Orthopaedic Surgery Physician	A155908	CA

General Provider Information

NPI Number	:	1396185161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS KUSNEZOV M.D.

Provider Business Mailing Address
First Line	:	5643 COPLEY DR STE 300
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-7903
Country	:	US
Telephone Number	:	858-455-9942
Fax Number	:	858-455-6473

Provider Business Practice Location Address
First Line	:	5643 COPLEY DR STE 300
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-7903
Country	:	US
Telephone Number	:	858-455-9942
Fax Number	:	858-455-6473

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

Provider Enumeration Date	:	06/26/2013
Last Update Date	:	05/02/2025

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