Healthcare Provider Details

I. General information

NPI: 1508277542
Provider Name (Legal Business Name): NICHOLAS F HRISOMALOS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 N ILLINOIS ST SUITE 1070
INDIANAPOLIS IN
46290-1167
US

IV. Provider business mailing address

10300 N ILLINOIS ST SUITE 1070
INDIANAPOLIS IN
46290-1167
US

V. Phone/Fax

Practice location:
  • Phone: 317-817-1500
  • Fax: 317-817-1511
Mailing address:
  • Phone: 317-817-1500
  • Fax: 317-817-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: STEFNIE JONES
Title or Position: OFFICE MANAGER
Credential:
Phone: 317-805-4595