MEDICARE: NICK B ANDONOV PHD

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	103TC0700X	Clinical Psychologist	PSY4792	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720127921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICK B ANDONOV PHD

Provider Business Mailing Address
First Line	:	2380 N SIERRA WAY
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92405-3546
Country	:	US
Telephone Number	:	909-883-5977
Fax Number	:	909-881-4070

Provider Business Practice Location Address
First Line	:	2380 N SIERRA WAY
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92405-3546
Country	:	US
Telephone Number	:	909-883-5977
Fax Number	:	909-881-4070

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/08/2007

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