Provider Demographics
NPI:1457766487
Name:POULOS, NICKOLAS EVANGELOS (DO)
Entity type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:EVANGELOS
Last Name:POULOS
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2208
Mailing Address - Country:US
Mailing Address - Phone:970-641-3927
Mailing Address - Fax:833-428-9482
Practice Address - Street 1:711 N TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2208
Practice Address - Country:US
Practice Address - Phone:970-641-9482
Practice Address - Fax:833-428-9482
Is Sole Proprietor?:No
Enumeration Date:2014-06-28
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13474207N00000X, 207ND0101X
CODR.0059273207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO029298OtherKAISER COMMERCIAL NUMBER
CO9000176165Medicaid