Provider Demographics
NPI:1104825926
Name:KIPREOS, NICHOLAS THEOPHILOS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:THEOPHILOS
Last Name:KIPREOS
Suffix:
Gender:M
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 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:276-694-6677
Mailing Address - Fax:
Practice Address - Street 1:865 W LAKE DR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2157
Practice Address - Country:US
Practice Address - Phone:336-719-6100
Practice Address - Fax:336-719-2313
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049407207Q00000X
NC2016-00121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005614236Medicaid
VA005614236Medicaid
VAF43610Medicare UPIN