Provider Demographics
NPI:1861416802
Name:NIKOU, SAM N (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:N
Last Name:NIKOU
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:PO BOX 6992
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-6992
Mailing Address - Country:US
Mailing Address - Phone:818-240-2242
Mailing Address - Fax:
Practice Address - Street 1:1300 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2506
Practice Address - Country:US
Practice Address - Phone:818-240-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA47763207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A447631Medicaid
CA00A477630Medicaid
CAWA47763BMedicare ID - Type Unspecified
CA00A447631Medicaid