Provider Demographics
NPI:1619998085
Name:NICOLAOU, NICOS (MD)
Entity Type:Individual
Prefix:
First Name:NICOS
Middle Name:
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 1:1 PRESIDENTIAL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1017
Mailing Address - Country:US
Mailing Address - Phone:610-632-4100
Mailing Address - Fax:610-668-1004
Practice Address - Street 1:1 PRESIDENTIAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1017
Practice Address - Country:US
Practice Address - Phone:610-632-4100
Practice Address - Fax:610-668-1004
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053676L2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016207530002Medicaid
PAG39963Medicare UPIN
PA0016207530002Medicaid