Healthcare Provider Details

I. General information

NPI: 1538274451
Provider Name (Legal Business Name): SOPHY DEDOPOULOS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 LAKEVILLE RD SUITE 107
NEW HYDE PARK NY
11042-1101
US

IV. Provider business mailing address

972 BRUSH HOLLOW RD 4TH FLOOR
WESTBURY NY
11590-1740
US

V. Phone/Fax

Practice location:
  • Phone: 516-465-5400
  • Fax: 516-465-5454
Mailing address:
  • Phone: 516-876-5555
  • Fax: 516-876-5539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number497423 / 303779
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number303779
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: