Provider Demographics
NPI:1144212853
Name:TRIANTAFILLOU, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:TRIANTAFILLOU
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 1:21305 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2044
Mailing Address - Country:US
Mailing Address - Phone:718-224-1378
Mailing Address - Fax:
Practice Address - Street 1:21305 39TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2044
Practice Address - Country:US
Practice Address - Phone:718-224-1378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199020207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01785964Medicaid
NY03966Medicare PIN
G61121Medicare UPIN
NY29N041Medicare PIN