Provider Demographics
NPI:1881782803
Name:SIMOPOULOS, NICHOLAS DEMETRIOS (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DEMETRIOS
Last Name:SIMOPOULOS
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 1:1000 FOWLER WAY
Mailing Address - Street 2:#5
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667
Mailing Address - Country:US
Mailing Address - Phone:530-626-1277
Mailing Address - Fax:530-626-3265
Practice Address - Street 1:1000 FOWLER WAY
Practice Address - Street 2:#5
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667
Practice Address - Country:US
Practice Address - Phone:530-626-1277
Practice Address - Fax:530-626-3265
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA234210208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A234210Medicaid
CA00A234210Medicare PIN
CAZZZ25270ZMedicare PIN
CAZZZ25271ZMedicare PIN
CAZZZ25269ZMedicare PIN
A86660Medicare UPIN