MEDICARE: JACK SOTERAKIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	107338	NY

General Provider Information

NPI Number	:	1598768624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK SOTERAKIS M.D.

Provider Business Mailing Address
First Line	:	100 PORT WASHINGTON BLVD
Second Line	:
City	:	ROSLYN
State	:	NY
Zip	:	11576-1353
Country	:	US
Telephone Number	:	516-562-6230
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 PORT WASHINGTON BLVD
Second Line	:
City	:	ROSLYN
State	:	NY
Zip	:	11576-1353
Country	:	US
Telephone Number	:	516-562-6230
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	09/22/2009

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