Provider Demographics
NPI:1205940855
Name:ANGELOPOULOS, NICHOLAS A (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:A
Last Name:ANGELOPOULOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 175
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0175
Mailing Address - Country:US
Mailing Address - Phone:708-429-3466
Mailing Address - Fax:
Practice Address - Street 1:6850 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1653
Practice Address - Country:US
Practice Address - Phone:708-429-3466
Practice Address - Fax:708-429-3422
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03689214207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089214Medicaid
ILK44273Medicare PIN
ILK04924Medicare ID - Type Unspecified
IL5998530001Medicare NSC
F85189Medicare UPIN