1144487968 NPI number — DR. VASILEIOS KOSTARAS MD

Table of content: MARILOU BRUZZINI LMT (NPI 1023405594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144487968 NPI number — DR. VASILEIOS KOSTARAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSTARAS
Provider First Name:
VASILEIOS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOSTARAS
Provider Other First Name:
VASILEIOS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1144487968
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 NICOLLS ROAD
Provider Second Line Business Mailing Address:
HSC 19
Provider Business Mailing Address City Name:
STONY BROOK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11794-8191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-444-1791
Provider Business Mailing Address Fax Number:
631-444-7689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 NICOLLS ROAD
Provider Second Line Business Practice Location Address:
HSC 19
Provider Business Practice Location Address City Name:
STONY BROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11794-8191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-444-1791
Provider Business Practice Location Address Fax Number:
631-444-7689
Provider Enumeration Date:
05/20/2008

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: 204F00000X , with the licence number:  MT191836 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: 256798 , 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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