Provider Demographics
NPI:1902804107
Name:ATHIENITES, NICOLAOS V (MD)
Entity type:Individual
Prefix:MR
First Name:NICOLAOS
Middle Name:V
Last Name:ATHIENITES
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:830 OAK ST
Mailing Address - Street 2:125E
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1168
Mailing Address - Country:US
Mailing Address - Phone:508-588-1505
Mailing Address - Fax:508-588-1508
Practice Address - Street 1:830 OAK ST
Practice Address - Street 2:125E
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1168
Practice Address - Country:US
Practice Address - Phone:508-588-1505
Practice Address - Fax:508-588-1508
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2024-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA73425207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
10246OtherHARVARD
760216OtherTUFTS
MA3079937Medicaid
J1127OtherBLUE CROSS
MA3079937Medicaid
MAJ11276Medicare PIN