Healthcare Provider Details

I. General information

NPI: 1386641454
Provider Name (Legal Business Name): PETER KANISTROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4983 DELHI AVE SUITE 6
CINCINNATI OH
45238-5380
US

IV. Provider business mailing address

1331 N ELM ST SUITE 200
GREENSBORO NC
27401-6302
US

V. Phone/Fax

Practice location:
  • Phone: 513-347-7237
  • Fax: 513-347-6567
Mailing address:
  • Phone: 336-274-9617
  • Fax: 336-482-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35072707K
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number35072703
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: