Provider Demographics
NPI:1033698139
Name:LOGOTHETIS, NICKOLAS (MD)
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:
Last Name:LOGOTHETIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10299 SOUTHERN BLVD # 212773
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-4337
Mailing Address - Country:US
Mailing Address - Phone:718-874-7569
Mailing Address - Fax:561-584-5551
Practice Address - Street 1:1317 EDGEWATER DR # 5300
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6350
Practice Address - Country:US
Practice Address - Phone:305-735-2452
Practice Address - Fax:561-584-5551
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2024-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA310796207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine