Provider Demographics
NPI:1376518548
Name:VASILIADIS, GEORGE (DPM)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:VASILIADIS
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 1:190 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-3334
Mailing Address - Country:US
Mailing Address - Phone:716-693-1050
Mailing Address - Fax:716-693-1240
Practice Address - Street 1:190 MAIN ST
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-3334
Practice Address - Country:US
Practice Address - Phone:716-693-1050
Practice Address - Fax:716-693-1240
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004647213EP0504X, 213EP1101X, 213ER0200X, 213ES0000X, 213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0076008OtherGROUP HEALTH
NY01195573Medicaid
NY8990088OtherINDEPENDENT HEALTH
NYY017440OtherTRICARE/ CHAMPUS
NY040426002701OtherFIDELIS CARE
NY00010257301OtherUNIVERA HEALTHCARE
NY000510938003OtherBC/ BS OF WNY
NY040426002701OtherFIDELIS CARE
NY0076008OtherGROUP HEALTH
NY8990088OtherINDEPENDENT HEALTH
NYCC3356Medicare PIN