Healthcare Provider Details

I. General information

NPI: 1508128455
Provider Name (Legal Business Name): NICHOLAS MICHAEL KITSOPOULOS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 YORK RD
CARLISLE PA
17013-3180
US

IV. Provider business mailing address

100 NORTH ACADEMY AVE.
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 717-218-3920
  • Fax: 717-218-3921
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOT014455
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS018326
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: