Healthcare Provider Details

I. General information

NPI: 1306919337
Provider Name (Legal Business Name): CONSTANTINE B VARDOPOULOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 DOGWOOD LN
NEWBURGH NY
12550-2027
US

IV. Provider business mailing address

141 DOGWOOD LN
NEWBURGH NY
12550-2027
US

V. Phone/Fax

Practice location:
  • Phone: 845-565-2153
  • Fax: 845-565-6688
Mailing address:
  • Phone: 845-565-2153
  • Fax: 845-565-6688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number096243
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: