Provider Demographics
NPI:1164996260
Name:STATHAKIOS, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:STATHAKIOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BARCLAY AVE NE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2527
Mailing Address - Country:US
Mailing Address - Phone:616-391-8810
Mailing Address - Fax:
Practice Address - Street 1:330 BARCLAY AVE NE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2527
Practice Address - Country:US
Practice Address - Phone:616-391-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X
MI4351051157208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No156F00000XEye and Vision Services ProvidersTechnician/Technologist