Basic Information
| Provider Information | |||||||||
| NPI: | 1104825926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIPREOS | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | THEOPHILOS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766946677 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 865 W LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367196100 | ||||||||
| FaxNumber: | 3367192313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101049407 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2016-00121 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005614236 | 05 | VA | MEDICAID |