Provider Demographics
NPI:1205138328
Name:NICK DZEBOLO MD INC
Entity type:Organization
Organization Name:NICK DZEBOLO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:N
Authorized Official - Last Name:DZEBOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-241-5072
Mailing Address - Street 1:1030 S GLENDALE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2866
Mailing Address - Country:US
Mailing Address - Phone:818-241-5072
Mailing Address - Fax:818-244-1768
Practice Address - Street 1:1030 S GLENDALE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2866
Practice Address - Country:US
Practice Address - Phone:818-241-5072
Practice Address - Fax:818-244-1768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty