Healthcare Provider Details

I. General information

NPI: 1225687098
Provider Name (Legal Business Name): DR. EVANGELOS NTRIVALAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

327 E 64TH ST
NEW YORK NY
10065-6704
US

V. Phone/Fax

Practice location:
  • Phone: 646-608-1394
  • Fax:
Mailing address:
  • Phone: 646-608-1394
  • Fax: 929-321-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License NumberNTRIE1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: