Healthcare Provider Details

I. General information

NPI: 1447702097
Provider Name (Legal Business Name): NICHOLAS POULOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11120 NEW HAMPSHIRE AVE SUITE 200
SILVER SPRING MD
20904-2633
US

IV. Provider business mailing address

11120 NEW HAMPSHIRE AVE SUITE 200
SILVER SPRING MD
20904-2633
US

V. Phone/Fax

Practice location:
  • Phone: 301-592-8200
  • Fax:
Mailing address:
  • Phone: 301-592-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA4567
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: