Healthcare Provider Details

I. General information

NPI: 1427219120
Provider Name (Legal Business Name): DAEMEON ACHILLES NICOLAOU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE 7TH FLOOR DESLOGE TOWERS
ST. LOUIS MO
63110
US

IV. Provider business mailing address

1008 S. SPRING ST. DEPARTMENT OF ORTHOPAEDIC SURGERY
SAINT LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8850
  • Fax: 314-268-5121
Mailing address:
  • Phone: 310-977-5330
  • Fax: 314-268-5121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2013021987
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number201301987
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA111473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: