Healthcare Provider Details

I. General information

NPI: 1861929861
Provider Name (Legal Business Name): THEOFANIS MITSINIKOS, DO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NESCONSET HWY BLDG 3C
STONY BROOK NY
11790-2551
US

IV. Provider business mailing address

2500 NESCONSET HWY BLDG 3C
STONY BROOK NY
11790-2551
US

V. Phone/Fax

Practice location:
  • Phone: 631-751-2400
  • Fax: 631-751-8323
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number235458
License Number StateNY

VIII. Authorized Official

Name: DR. THEOFANIS MITSINIKOS
Title or Position: OWNER
Credential: DO
Phone: 631-751-2400