Provider Demographics
NPI:1912972415
Name:KOUTRELAKOS, NICHOLAS WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:WILLIAM
Last Name:KOUTRELAKOS
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 1:10710 CHARTER DR
Mailing Address - Street 2:SUITE G020
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3128
Mailing Address - Country:US
Mailing Address - Phone:410-964-2212
Mailing Address - Fax:410-964-0380
Practice Address - Street 1:10710 CHARTER DR
Practice Address - Street 2:SUITE G020
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3128
Practice Address - Country:US
Practice Address - Phone:410-964-2212
Practice Address - Fax:410-964-0380
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0038509207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD533151000Medicaid
E20296Medicare UPIN
MD533151000Medicaid