Provider Demographics
NPI:1114907730
Name:PSALIDAS, PANAGIOTIS GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:PANAGIOTIS
Middle Name:GEORGE
Last Name:PSALIDAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W 27TH ST RM A402
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-5992
Mailing Address - Country:US
Mailing Address - Phone:212-217-4190
Mailing Address - Fax:212-217-4191
Practice Address - Street 1:245 ENGLE STREET
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631
Practice Address - Country:US
Practice Address - Phone:201-569-9005
Practice Address - Fax:201-569-9080
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07276300208000000X, 207R00000X
NY204950208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01884459Medicaid
NJD087424OtherCDS
NJ0124842Medicaid
NYG81308Medicare UPIN
NY01884459Medicaid