Provider Demographics
NPI:1992235311
Name:THEODOSAKIS, NICHOLAS II (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:THEODOSAKIS
Suffix:II
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST # BH616
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2696
Mailing Address - Country:US
Mailing Address - Phone:617-726-2914
Mailing Address - Fax:
Practice Address - Street 1:50 STANIFORD ST STE 200
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2543
Practice Address - Country:US
Practice Address - Phone:617-726-2914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA287040207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology