Basic Information
Provider Information
NPI: 1003017666
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NITZEL
FirstName: CORY
MiddleName: MICHAEL LEE
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 413033
Address2:  
City: SALT LAKE CITY
State: UT
PostalCode: 841413033
CountryCode: US
TelephoneNumber: 8012133900
FaxNumber:  
Practice Location
Address1: 300 HILLMONT AVE STE 503
Address2:  
City: VENTURA
State: CA
PostalCode: 930031651
CountryCode: US
TelephoneNumber: 8056525787
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/30/2007
LastUpdateDate: 03/26/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/26/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0000XC155200CAY Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
207RC0000X7676143-1205UTN Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease

No ID Information.


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