Provider Demographics
NPI:1184676181
Name:NICOLAOU, DAVID DARWIN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DARWIN
Last Name:NICOLAOU
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 1:2971 CRESCENT SHORES DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9643
Mailing Address - Country:US
Mailing Address - Phone:231-933-1540
Mailing Address - Fax:
Practice Address - Street 1:550 MUNSON AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:231-935-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45394207P00000X
MI4301084991207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104957619Medicaid
MD131961200Medicaid
DN084991OtherBCBS
MD131961200Medicaid
MDS806JOMedicare ID - Type UnspecifiedGROUP
MI104957619Medicaid
P38800010Medicare PIN