Healthcare Provider Details

I. General information

NPI: 1801059860
Provider Name (Legal Business Name): NICHOLAS ALEX ATHANASIOU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MOUNT VERNON AVE RM # 3057
BAKERSFIELD CA
93306-4018
US

IV. Provider business mailing address

1700 MOUNT VERNON AVE RM # 3057
BAKERSFIELD CA
93306-4018
US

V. Phone/Fax

Practice location:
  • Phone: 661-326-2253
  • Fax:
Mailing address:
  • Phone: 661-326-2253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA110558
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA110558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: