Basic Information
| Provider Information | |||||||||
| NPI: | 1871564559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOUSTOUKAS | ||||||||
| FirstName: | NICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 PRYTANIA ST | ||||||||
| Address2: | SUITE 35 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701153628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048978315 | ||||||||
| FaxNumber: | 5048919862 | ||||||||
| Practice Location | |||||||||
| Address1: | 3715 PRYTANIA ST | ||||||||
| Address2: | STE 400 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701153761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048978276 | ||||||||
| FaxNumber: | 5048978336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 06/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 015305 | LA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 1355160 | 05 | LA | MEDICAID |