Healthcare Provider Details

I. General information

NPI: 1376518548
Provider Name (Legal Business Name): GEORGE VASILIADIS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 MAIN ST
TONAWANDA NY
14150-3334
US

IV. Provider business mailing address

190 MAIN ST
TONAWANDA NY
14150-3334
US

V. Phone/Fax

Practice location:
  • Phone: 716-693-1050
  • Fax: 716-693-1240
Mailing address:
  • Phone: 716-693-1050
  • Fax: 716-693-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License NumberN004647
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN004647
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberN004647
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberN004647
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN004647
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN004647
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: