Provider Demographics
NPI:1245231588
Name:KALLIANOS, JOHN ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:KALLIANOS
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 1:4309 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2388
Mailing Address - Country:US
Mailing Address - Phone:919-471-4484
Mailing Address - Fax:919-477-6131
Practice Address - Street 1:4309 MEDICAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2388
Practice Address - Country:US
Practice Address - Phone:919-471-4484
Practice Address - Fax:919-477-6131
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31730207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8947766Medicaid
NC212351BMedicare ID - Type Unspecified
NCC87518Medicare UPIN