Provider Demographics
NPI:1336647213
Name:INTEGRATIVE MEDICINE OF BROOKHAVEN P.C.
Entity Type:Organization
Organization Name:INTEGRATIVE MEDICINE OF BROOKHAVEN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DIMOS
Authorized Official - Middle Name:G
Authorized Official - Last Name:KANAKOUDAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-824-1380
Mailing Address - Street 1:7 LOST MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:59 NESCONSET HWY FL 2
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2628
Practice Address - Country:US
Practice Address - Phone:646-824-1380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty