Healthcare Provider Details

I. General information

NPI: 1144238650
Provider Name (Legal Business Name): NICO MOUSDICAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 W CARMEL DR SUITE 101
CARMEL IN
46032-5877
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 130 PROVIDER ENROLLMENT
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-846-2396
  • Fax: 317-846-1699
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01061689A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: