Healthcare Provider Details

I. General information

NPI: 1134862790
Provider Name (Legal Business Name): ATHANASIOS ANGISTRIOTIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HEALTH SCIENCE TOWER LEVEL 19, ROOM 030
STONY BROOK NY
11794-8191
US

IV. Provider business mailing address

HEALTH SCIENCE TOWER LEVEL 19, ROOM 030
STONY BROOK NY
11794-8191
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-1791
  • Fax: 631-444-7689
Mailing address:
  • Phone: 631-444-1791
  • Fax: 631-444-7689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: