Healthcare Provider Details

I. General information

NPI: 1184538803
Provider Name (Legal Business Name): DEMETRA VASILIADIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 MAIN ST
FLUSHING NY
11355-5045
US

IV. Provider business mailing address

14314 14TH AVE
WHITESTONE NY
11357-2331
US

V. Phone/Fax

Practice location:
  • Phone: 718-670-2000
  • Fax:
Mailing address:
  • Phone: 718-813-5913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number979576
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: