Provider Demographics
NPI:1669446894
Name:POULOS, NICHOLAS D (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:D
Last Name:POULOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4100
Mailing Address - Fax:
Practice Address - Street 1:6535 NEMOURS PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7884
Practice Address - Country:US
Practice Address - Phone:407-650-7000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME909812086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270512500Medicaid
GA667777318AMedicaid
G22645Medicare UPIN
GA667777318AMedicaid