Provider Demographics
NPI:1407953987
Name:NACOPOULOS, GREGORY C (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:C
Last Name:NACOPOULOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1114
Mailing Address - Country:US
Mailing Address - Phone:618-546-2618
Mailing Address - Fax:618-546-2648
Practice Address - Street 1:1000 N ALLEN ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1114
Practice Address - Country:US
Practice Address - Phone:618-546-2618
Practice Address - Fax:618-546-2648
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102151208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01627719OtherBLUE SHIELD OF IL
IL036102151Medicaid
ILH46974Medicare UPIN
IL01627719OtherBLUE SHIELD OF IL