Provider Demographics
NPI:1255383386
Name:ECONOMIDES, NICHOLAS J (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:ECONOMIDES
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 1:6005 PARK AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5217
Mailing Address - Country:US
Mailing Address - Phone:901-255-3003
Mailing Address - Fax:
Practice Address - Street 1:6005 PARK AVE STE 700
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5217
Practice Address - Country:US
Practice Address - Phone:901-255-3003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12742086X0206X
OH35-08-17722086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000239823OtherANTHEM BCBS
240007884OtherRR MEDICARE
001714145OtherMOUNTAIN STATE BCBS
B59463Medicare UPIN
WV2003870000Medicaid
000000239823OtherANTHEM BCBS
OH2363553OtherMOLINA MEDICAID
OH2363553Medicaid
001714145OtherMOUNTAIN STATE BCBS
240007884OtherRR MEDICARE