Provider Demographics
NPI:1093847568
Name:PEDIADITAKIS, NICHOLAS (MD, DLFAPA)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:PEDIADITAKIS
Suffix:
Gender:M
Credentials:MD, DLFAPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 LEAD MINE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3436
Mailing Address - Country:US
Mailing Address - Phone:919-787-0710
Mailing Address - Fax:919-787-0710
Practice Address - Street 1:5100 LEAD MINE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-3436
Practice Address - Country:US
Practice Address - Phone:919-787-0710
Practice Address - Fax:919-787-0710
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC132012084P0800X, 2084P0805X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC66509OtherBLUE CROSS BLUE SHIELD
NC8966509Medicaid
NC8966509Medicaid