Provider Demographics
NPI:1255663068
Name:STEFANOU, DEMOS
Entity Type:Individual
Prefix:MR
First Name:DEMOS
Middle Name:
Last Name:STEFANOU
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 1:23 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-3827
Mailing Address - Country:US
Mailing Address - Phone:516-797-5838
Mailing Address - Fax:
Practice Address - Street 1:4250 JERUSALEM AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-3315
Practice Address - Country:US
Practice Address - Phone:516-798-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist