Provider Demographics
NPI:1124019757
Name:ATHANASOULIS, CHRISTOS A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOS
Middle Name:A
Last Name:ATHANASOULIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:GRB 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-8319
Practice Address - Fax:617-726-8476
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA328032085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA032803OtherTUFTS HEALTH PLAN
MA2085127Medicaid
MAM08036OtherBCBS MA
MA2085127Medicaid
A66014Medicare UPIN