Provider Demographics
NPI:1073033213
Name:KOULISIS, NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KOULISIS
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 1:5400 BALBOA BLVD STE 126
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5202
Mailing Address - Country:US
Mailing Address - Phone:818-578-0004
Mailing Address - Fax:818-578-0002
Practice Address - Street 1:5400 BALBOA BLVD STE 126
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5202
Practice Address - Country:US
Practice Address - Phone:818-578-0004
Practice Address - Fax:818-578-0002
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA157849207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology