Healthcare Provider Details

I. General information

NPI: 1235311218
Provider Name (Legal Business Name): MR. KOSTANTINOS VASALOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LACDEVILLE BLVD BUILDING D SUITE 110
ROCHESTER NY
14618-5647
US

IV. Provider business mailing address

4901 LACDEVILLE BLVD BUILDING D SUITE 110
ROCHESTER NY
14618-5647
US

V. Phone/Fax

Practice location:
  • Phone: 585-341-9150
  • Fax:
Mailing address:
  • Phone: 585-341-9150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number026332
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: