Individual
NICO MOUSDICAS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
755 W CARMEL DR, SUITE 101, CARMEL, IN 46032-5877
(317) 846-2396
(317) 846-1699
Mailing address
250 N SHADELAND AVE, STE 130 PROVIDER ENROLLMENT, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
01061689A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000334111
ANTHEM
IN
01
—
000000563670
ANTHEM
IN
05
—
200488150
—
IN
Enumeration date
08/03/2006
Last updated
02/18/2014
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