Healthcare Provider Details

I. General information

NPI: 1225032097
Provider Name (Legal Business Name): JOHN TSOURIS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 NESCONSET HWY SUITE 206
LAKE GROVE NY
11755-1000
US

IV. Provider business mailing address

2233 NESCONSET HWY SUITE 206
LAKE GROVE NY
11755-1000
US

V. Phone/Fax

Practice location:
  • Phone: 631-751-4603
  • Fax: 631-751-8166
Mailing address:
  • Phone: 631-751-4603
  • Fax: 631-751-8166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN004604
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN004604
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberN004604
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN004604
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: