1720364367 NPI number — PETROS KONOFAOS M.D., PHD

Table of content: PETROS KONOFAOS M.D., PHD (NPI 1720364367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720364367 NPI number — PETROS KONOFAOS M.D., PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONOFAOS
Provider First Name:
PETROS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D., PHD
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:
1720364367
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650859
Provider Second Line Business Mailing Address:
DEPT. 710
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-772-2222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 HARBORSIDE DR
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
GALVESTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77555-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-772-8115
Provider Business Practice Location Address Fax Number:
409-772-1872
Provider Enumeration Date:
10/27/2011

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: 208200000X , with the licence number:  U1064 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: MD50989 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: U1064 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X , with the licence number: U1064 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08231501 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003180136A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q007443 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1720364367 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 177445 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 204025001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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