Provider Demographics
NPI:1407415672
Name:KOULLAS, NICHOLAS (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:KOULLAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 CLIFTON RD NE
Mailing Address - Street 2:BLDG A FLR 2
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:BLDG A FLR 2
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322
Practice Address - Country:US
Practice Address - Phone:404-778-7973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA105423208600000X
GA12155208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery