Provider Demographics
NPI:1659310753
Name:NIKITAS, NICHOLAS J (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:NIKITAS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:EVANSTON HOSPITAL RM 1210
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-1206
Mailing Address - Fax:847-570-1248
Practice Address - Street 1:103 S GREENLEAF ST
Practice Address - Street 2:SUITE J
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3380
Practice Address - Country:US
Practice Address - Phone:847-599-8899
Practice Address - Fax:847-599-8997
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-01-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036089966207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F75463Medicare UPIN
K15150Medicare ID - Type Unspecified