MEDICARE: NICKOLAS KATSOULAKIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	LP00389	RI
2	207W00000X	Ophthalmology Physician	247724	NY
3	207W00000X	Ophthalmology Physician	036123759	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00673435	OTHER	NY	PALMETTO
2	650A31	OTHER	NY	EMPIRE BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1902023088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICKOLAS KATSOULAKIS M.D.

Provider Business Mailing Address
First Line	:	7340 W COLLEGE DR
Second Line	:	2ND FLOOR
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1159
Country	:	US
Telephone Number	:	708-361-7800
Fax Number	:	708-361-8737

Provider Business Practice Location Address
First Line	:	7340 W COLLEGE DR
Second Line	:	2ND FLOOR
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1159
Country	:	US
Telephone Number	:	708-361-7800
Fax Number	:	708-361-8737

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	02/18/2010

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Directions to “ NICKOLAS KATSOULAKIS M.D.” Practice Location

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