Provider Demographics
NPI:1518002278
Name:NICKOLAKIS, IRENE ANDREA (MD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:ANDREA
Last Name:NICKOLAKIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S PINELLAS AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-1955
Mailing Address - Country:US
Mailing Address - Phone:727-938-0714
Mailing Address - Fax:727-938-9513
Practice Address - Street 1:1501 S PINELLAS AVE
Practice Address - Street 2:SUITE K
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-1955
Practice Address - Country:US
Practice Address - Phone:727-938-0714
Practice Address - Fax:727-938-9513
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00558772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE84316Medicare UPIN
FL12213ZMedicare ID - Type UnspecifiedINDIVIDUAL