Healthcare Provider Details

I. General information

NPI: 1659549061
Provider Name (Legal Business Name): CONSTANTINE DEMETRIADIS LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 5TH AVE FL 7
NEW YORK NY
10018-0223
US

IV. Provider business mailing address

420 5TH AVE FL 7
NEW YORK NY
10018-0223
US

V. Phone/Fax

Practice location:
  • Phone: 646-682-5343
  • Fax:
Mailing address:
  • Phone: 646-682-5343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1917
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number004077
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: