Provider Demographics
NPI:1144228453
Name:NIKOULA, JAWDAT A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAWDAT
Middle Name:A
Last Name:NIKOULA
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 1:905 SPRUCE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:IRWIN
Mailing Address - State:PA
Mailing Address - Zip Code:15642-3683
Mailing Address - Country:US
Mailing Address - Phone:724-864-9595
Mailing Address - Fax:724-864-9860
Practice Address - Street 1:905 SPRUCE ST STE 201
Practice Address - Street 2:
Practice Address - City:IRWIN
Practice Address - State:PA
Practice Address - Zip Code:15642-3683
Practice Address - Country:US
Practice Address - Phone:724-864-9595
Practice Address - Fax:724-864-9860
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032696E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3219OtherMEDICARE (RAILROAD)
PA0009874960001Medicaid
CA3219OtherMEDICARE
PA193407LLBMedicare PIN