Provider Demographics
NPI:1013119551
Name:NICOLA DEMACOPOULOS MD INC
Entity Type:Organization
Organization Name:NICOLA DEMACOPOULOS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEMACOPOULSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-638-0068
Mailing Address - Street 1:310 WINSOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-2705
Mailing Address - Country:US
Mailing Address - Phone:330-638-0068
Mailing Address - Fax:330-637-0067
Practice Address - Street 1:310 WINSOR DRIVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-2705
Practice Address - Country:US
Practice Address - Phone:330-638-0068
Practice Address - Fax:330-637-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063150D207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0874915Medicaid
000000283762OtherANTHEM
000000283762OtherANTHEM
OHF26151Medicare UPIN