=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053438044
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREAS EVDOKAS PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 5TH AVE SUITE 903 ROOM 12
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-8002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-330-8133
-----------------------------------------------------
Fax | 212-330-8116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 GARDEN ST APT 1
-----------------------------------------------------
City | HOBOKEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07030-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 013512
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------