Basic Information
| Provider Information | |||||||||
| NPI: | 1902023088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KATSOULAKIS | ||||||||
| FirstName: | NICKOLAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7340 W COLLEGE DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083617800 | ||||||||
| FaxNumber: | 7083618737 | ||||||||
| Practice Location | |||||||||
| Address1: | 7340 W COLLEGE DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083617800 | ||||||||
| FaxNumber: | 7083618737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | LP00389 | RI | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 247724 | NY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 036123759 | IL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | P00673435 | 01 | NY | PALMETTO | OTHER | 650A31 | 01 | NY | EMPIRE BLUE CROSS BLUE SHIELD | OTHER |