Provider Demographics
NPI:1720059637
Name:PSOMIADIS, NICOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:
Last Name:PSOMIADIS
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 1:214 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3402
Mailing Address - Country:US
Mailing Address - Phone:706-647-9627
Mailing Address - Fax:706-647-9651
Practice Address - Street 1:214 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3402
Practice Address - Country:US
Practice Address - Phone:706-647-9627
Practice Address - Fax:706-647-9651
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053022207V00000X
AL24948207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009918635Medicaid
AL51553516OtherBCBS
H82105Medicare UPIN
051553516Medicare ID - Type Unspecified