Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | L3414 | TX |
NPI | 1033181813 |
---|---|
Provider Name | Dr. Gregory A. Nikolaidis |
First Address | Austin, TX 78746-4719 |
Second Address | Austin, TX 78746-4719 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2006 |
Last Update Date | 06/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8347B6 | BCBS OF TEXAS INDIVIDUAL # (01) | TX |
H07754 | (02) | TX |