Provider Demographics
NPI:1114047446
Name:SOUMELIDIS, NICKOLAS N (MD)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:N
Last Name:SOUMELIDIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NICKOLAY
Other - Middle Name:NICKOLAEVICH
Other - Last Name:POLIANSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7562 W.GULF TO LAKE HWY
Mailing Address - Street 2:CHRIST MEDICAL CENTER
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429
Mailing Address - Country:US
Mailing Address - Phone:352-688-9558
Mailing Address - Fax:
Practice Address - Street 1:3027 LANDOVER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-7260
Practice Address - Country:US
Practice Address - Phone:352-688-9558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103560207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00811506OtherRR MEDICARE
FL001438200Medicaid
FLCK174ZMedicare PIN