Provider Demographics
NPI:1225032097
Name:TSOURIS, JOHN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:TSOURIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 NESCONSET HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1000
Mailing Address - Country:US
Mailing Address - Phone:631-751-4603
Mailing Address - Fax:631-751-8166
Practice Address - Street 1:2233 NESCONSET HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1000
Practice Address - Country:US
Practice Address - Phone:631-751-4603
Practice Address - Fax:631-751-8166
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004604213E00000X, 213EP1101X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP5120P1421Medicare PIN
NYU11181Medicare UPIN
NYP5120-1Medicare ID - Type Unspecified