Healthcare Provider Details

I. General information

NPI: 1255405767
Provider Name (Legal Business Name): TOM STATHAKIOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD
DEARBORN MI
48124-4089
US

IV. Provider business mailing address

2 COLUMBIA DR SUTIE A327
TAMPA FL
33606-3508
US

V. Phone/Fax

Practice location:
  • Phone: 313-436-2374
  • Fax:
Mailing address:
  • Phone: 813-844-4396
  • Fax: 813-844-4972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number058286
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: