Provider Demographics
NPI:1457766487
Name:POULOS, NICKOLAS EVANGELOS (DO)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:EVANGELOS
Last Name:POULOS
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 1:6071 E WOODMEN RD STE 230
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-2607
Mailing Address - Country:US
Mailing Address - Phone:719-505-0105
Mailing Address - Fax:719-284-4626
Practice Address - Street 1:6071 E WOODMEN RD STE 230
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-2607
Practice Address - Country:US
Practice Address - Phone:719-505-0105
Practice Address - Fax:719-284-4626
Is Sole Proprietor?:No
Enumeration Date:2014-06-28
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0059273207N00000X
FLOS13474207N00000X
FLUO4276390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000176165Medicaid
CO029298OtherKAISER COMMERCIAL NUMBER