Healthcare Provider Details

I. General information

NPI: 1083092126
Provider Name (Legal Business Name): NIKOLAOS CHRISTOS ZAGORIANOS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 BLUEGRASS AVE SUITE 200
LOUISVILLE KY
40215-1179
US

IV. Provider business mailing address

1935 BLUEGRASS AVE SUITE 200
LOUISVILLE KY
40215-1179
US

V. Phone/Fax

Practice location:
  • Phone: 502-364-0033
  • Fax: 502-361-4488
Mailing address:
  • Phone: 502-364-0033
  • Fax: 502-361-4488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8434T
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003891A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1975DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: