Provider Demographics
NPI:1497081616
Name:STATHATOS, NIKOLAOS (MD)
Entity Type:Individual
Prefix:
First Name:NIKOLAOS
Middle Name:
Last Name:STATHATOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NIKOLAOS
Other - Middle Name:A
Other - Last Name:STATHATOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:15 FRUIT ST
Mailing Address - Street 2:WANG ACC 730S
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-726-3872
Mailing Address - Fax:617-726-5905
Practice Address - Street 1:15 FRUIT ST
Practice Address - Street 2:WANG ACC 730S
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-3872
Practice Address - Fax:617-726-5905
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA242408207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism