Provider Demographics
NPI:1548266299
Name:TARASIDIS, NICHOLAS GEORGE (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GEORGE
Last Name:TARASIDIS
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 1:161 WADSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236-4500
Mailing Address - Country:US
Mailing Address - Phone:804-484-3700
Mailing Address - Fax:804-320-6462
Practice Address - Street 1:161 WADSWORTH DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23236-4500
Practice Address - Country:US
Practice Address - Phone:804-484-3700
Practice Address - Fax:804-320-6462
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046413207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
040000308Medicare ID - Type Unspecified
E82999Medicare UPIN