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General NPI Number Information
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NPI Number | 1336647213
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE MEDICINE OF BROOKHAVEN P.C.
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Dates
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Enumeration Date | 01/25/2018
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Last Update Date | 03/14/2021
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Provider Practice Location Address
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Address Line | 59 NESCONSET HWY FL 2
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-2628
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Country | US
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Telephone | 646-824-1380
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Fax |
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Provider Business Mailing Address
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Address Line | 7 LOST MEADOW LN
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-1127
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/MEDICAL DIRECTOR
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Name | DR. DIMOS G KANAKOUDAS
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Credential | MD
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Telephone | 646-824-1380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 257261
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License Number State | NY
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