Healthcare Provider Details

I. General information

NPI: 1023172285
Provider Name (Legal Business Name): KONSTANTOINOS PETINOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15849 84TH ST
HOWARD BEACH NY
11414-3020
US

IV. Provider business mailing address

158 49 84TH STREET
HOWARD BEACH NY
11414
US

V. Phone/Fax

Practice location:
  • Phone: 718-322-7425
  • Fax: 718-322-5541
Mailing address:
  • Phone: 718-322-7425
  • Fax: 718-322-5541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number171264 1
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: