Provider Demographics
NPI:1568452340
Name:HRISOMALOS, NICHOLAS FRANK (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:FRANK
Last Name:HRISOMALOS
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:10300 N ILLINOIS ST
Mailing Address - Street 2:SUITE1070
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1167
Mailing Address - Country:US
Mailing Address - Phone:317-817-1500
Mailing Address - Fax:317-817-1511
Practice Address - Street 1:10300 N ILLINOIS ST
Practice Address - Street 2:SUITE1070
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1167
Practice Address - Country:US
Practice Address - Phone:317-817-1500
Practice Address - Fax:317-817-1511
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01032013B207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1940OtherMEDICARE ID
IN100228280Medicaid
ININ1940OtherMEDICARE ID