Healthcare Provider Details

I. General information

NPI: 1114185394
Provider Name (Legal Business Name): NICHOLAS NASRY TADROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2008
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 ST FRANCIS WAY STE 105
LAFAYETTE IN
47905-4917
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 765-428-1660
  • Fax: 765-428-1627
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01100336A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35.128008
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-144237
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: