Healthcare Provider Details

I. General information

NPI: 1497960124
Provider Name (Legal Business Name): DEMETRA MITSOTAKIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 W 6TH ST
BROOKLYN NY
11204-4802
US

IV. Provider business mailing address

86 85TH ST
BROOKLYN NY
11209-4208
US

V. Phone/Fax

Practice location:
  • Phone: 718-256-1057
  • Fax: 718-256-4912
Mailing address:
  • Phone: 718-759-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number230996
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: