Provider Demographics
NPI:1033157656
Name:SOUFLERIS, NICKIE K (MD)
Entity Type:Individual
Prefix:DR
First Name:NICKIE
Middle Name:K
Last Name:SOUFLERIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MTN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-0178
Mailing Address - Country:US
Mailing Address - Phone:423-266-5427
Mailing Address - Fax:423-266-5428
Practice Address - Street 1:113 STRINGER ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-3254
Practice Address - Country:US
Practice Address - Phone:423-266-5427
Practice Address - Fax:423-266-5428
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD24710174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4068642OtherBCBS PROVIDER #
TNMD24710OtherMD LICENSE #
TNF18060Medicare UPIN
TN3089668Medicare ID - Type Unspecified