Provider Demographics
NPI:1487642682
Name:STATHOPOULOS, NICHOLAS A (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:A
Last Name:STATHOPOULOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1890 COLVIN BLVD
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-6964
Mailing Address - Country:US
Mailing Address - Phone:716-837-5200
Mailing Address - Fax:716-837-8750
Practice Address - Street 1:1890 COLVIN BLVD
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-6964
Practice Address - Country:US
Practice Address - Phone:716-837-5200
Practice Address - Fax:716-837-8750
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA205998207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001804278Medicaid
NY01748136Medicaid
NY01748136Medicaid
PA038677E41Medicare ID - Type Unspecified
PA001804278Medicaid