Provider Demographics
NPI:1013283472
Name:SOPKO, NIKOLAI (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:NIKOLAI
Middle Name:
Last Name:SOPKO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:775 POLE LINE RD W STE 301
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5823
Practice Address - Country:US
Practice Address - Phone:208-814-8700
Practice Address - Fax:208-933-4914
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-15541208800000X
MDAJ414735208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology