1902804107 NPI number — MR. NICOLAOS V ATHIENITES M.D.

Table of content: MR. NICOLAOS V ATHIENITES M.D. (NPI 1902804107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902804107 NPI number — MR. NICOLAOS V ATHIENITES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ATHIENITES
Provider First Name:
NICOLAOS
Provider Middle Name:
V
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902804107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 OAK ST
Provider Second Line Business Mailing Address:
125E
Provider Business Mailing Address City Name:
BROCKTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02301-1168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-588-1505
Provider Business Mailing Address Fax Number:
508-588-1508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 OAK ST
Provider Second Line Business Practice Location Address:
125E
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301-1168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-588-1505
Provider Business Practice Location Address Fax Number:
508-588-1508
Provider Enumeration Date:
07/12/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  73425 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10246 . This is a "HARVARD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 760216 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3079937 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J1127 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".