Provider Demographics
NPI:1902023088
Name:KATSOULAKIS, NICKOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:
Last Name:KATSOULAKIS
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 1:7340 W COLLEGE DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1159
Mailing Address - Country:US
Mailing Address - Phone:708-361-7800
Mailing Address - Fax:708-361-8737
Practice Address - Street 1:7340 W COLLEGE DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1159
Practice Address - Country:US
Practice Address - Phone:708-361-7800
Practice Address - Fax:708-361-8737
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP00389207W00000X
NY247724207W00000X
IL036123759207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00673435OtherPALMETTO
NY650A31OtherEMPIRE BLUE CROSS BLUE SHIELD
NYP00673435OtherPALMETTO