Provider Demographics
NPI:1144896234
Name:NISHIJIMA, NICKLAUS
Entity type:Individual
Prefix:
First Name:NICKLAUS
Middle Name:
Last Name:NISHIJIMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2067 W VISTA WAY STE 265
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6034
Mailing Address - Country:US
Mailing Address - Phone:760-463-9155
Mailing Address - Fax:
Practice Address - Street 1:2067 W VISTA WAY STE 265
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6034
Practice Address - Country:US
Practice Address - Phone:760-463-9155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-31
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAE6118213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program