Provider Demographics
NPI:1538327309
Name:COUNTRYMAN, NICHOLAS B (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:B
Last Name:COUNTRYMAN
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 1:10507 HYDE PARK
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8300
Mailing Address - Country:US
Mailing Address - Phone:317-853-6227
Mailing Address - Fax:
Practice Address - Street 1:7910 N SHADELAND AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2041
Practice Address - Country:US
Practice Address - Phone:317-516-5000
Practice Address - Fax:317-516-5146
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00203207N00000X, 207ND0101X
IN01069284A207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery