Provider Demographics
NPI:1861566507
Name:YARU, NICHOLAS CORNELL (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:CORNELL
Last Name:YARU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 AVOCADO AVE
Mailing Address - Street 2:SUITE 802
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7721
Mailing Address - Country:US
Mailing Address - Phone:949-644-9000
Mailing Address - Fax:949-644-9330
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:SUITE 802
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7721
Practice Address - Country:US
Practice Address - Phone:949-644-9000
Practice Address - Fax:949-644-9330
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47315207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G473150Medicaid
CAG47315OtherMEDICARE ID
200004146OtherMEDICARE RAILROAD
CA6500090001OtherPROVIDER TRANSACTION ACCESS NUMBER, NSC SUPPLIER NUMBER
CA00G473150Medicaid
G47315Medicare PIN
6500090001Medicare NSC