Healthcare Provider Details

I. General information

NPI: 1942610621
Provider Name (Legal Business Name): JOHN MITSIOS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 YORK AVE
NEW YORK NY
10065-4805
US

IV. Provider business mailing address

4535 FOREST PARK AVE APT 314
SAINT LOUIS MO
63108-2128
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-6464
  • Fax:
Mailing address:
  • Phone: 314-691-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: