Healthcare Provider Details

I. General information

NPI: 1982839346
Provider Name (Legal Business Name): ANTHONY JAMES DEDOUSIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE R BUILDING, SECOND FLOOR
BROOKLYN NY
11203-2054
US

IV. Provider business mailing address

451 CLARKSON AVE R BUILDING, SECOND FLOOR
BROOKLYN NY
11203-2054
US

V. Phone/Fax

Practice location:
  • Phone: 718-245-3286
  • Fax:
Mailing address:
  • Phone: 718-245-3286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number156931
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number274056
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number156931
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number274056
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: