Provider Demographics
NPI:1144254467
Name:KAMBOURIS, NICHOLAS G (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:G
Last Name:KAMBOURIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:11510 GEORGIA AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-1925
Mailing Address - Country:US
Mailing Address - Phone:301-946-5100
Mailing Address - Fax:301-929-0348
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:301-946-5100
Practice Address - Fax:301-929-0348
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCMD31519207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC501329OtherNCPPO
DC9431215002OtherCIGNA HMO
DC209468OtherKAISER
DC0108OtherCAREFIRST BCBS
DC5366647OtherAETNA NON HMO
VA441040OtherANTHEM BCBS
DC2495273OtherAETNA HMO
VA5704634Medicaid
DC209468OtherKAISER
DC00A267C13Medicare ID - Type UnspecifiedTRAILBLAZER MEDICARE