Provider Demographics
NPI:1760611867
Name:KANELLOPOULOS, NIKOLAOS (MD)
Entity Type:Individual
Prefix:DR
First Name:NIKOLAOS
Middle Name:
Last Name:KANELLOPOULOS
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 1:260 N TROPICAL TRL STE 105
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4800
Mailing Address - Country:US
Mailing Address - Phone:321-208-8258
Mailing Address - Fax:321-735-7186
Practice Address - Street 1:260 N TROPICAL TRL STE 105
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4800
Practice Address - Country:US
Practice Address - Phone:321-208-8258
Practice Address - Fax:321-735-7186
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113375207Q00000X
IL125057050390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006384900Medicaid
FLP01412400OtherRRMR
FLGJ504YOtherMEDICARE
FLME113375OtherFL LICENSE