Provider Demographics
NPI:1164271375
Name:DIAMANTOPOULOS, NICHOLAS
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:DIAMANTOPOULOS
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 1:20 SANTA VICTORIA AISLE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-0863
Mailing Address - Country:US
Mailing Address - Phone:949-870-8005
Mailing Address - Fax:
Practice Address - Street 1:27881 LA PAZ RD
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-3933
Practice Address - Country:US
Practice Address - Phone:949-643-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH40861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist