1447694153 NPI number — DEMETRIOS MIKELIS M.D.

Table of content: DEMETRIOS MIKELIS M.D. (NPI 1447694153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447694153 NPI number — DEMETRIOS MIKELIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIKELIS
Provider First Name:
DEMETRIOS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447694153
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 CHASE RD
Provider Second Line Business Mailing Address:
PO BOX 701
Provider Business Mailing Address City Name:
SCARSDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10583-7500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 MARCUS AVE
Provider Second Line Business Practice Location Address:
SUITE 170 WEST
Provider Business Practice Location Address City Name:
NEW HYDE PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11042-2061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-355-0111
Provider Business Practice Location Address Fax Number:
516-355-5011
Provider Enumeration Date:
04/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  216578 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 216578 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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