Healthcare Provider Details

I. General information

NPI: 1265405161
Provider Name (Legal Business Name): PETER STATHOPOULOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 CASTLETON AVE
STATEN ISLAND NY
10310-1809
US

IV. Provider business mailing address

856 CASTLETON AVE
STATEN ISLAND NY
10310-1809
US

V. Phone/Fax

Practice location:
  • Phone: 718-720-6300
  • Fax: 718-720-2130
Mailing address:
  • Phone: 718-720-6300
  • Fax: 718-720-2130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number159747
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: