Provider Demographics
NPI:1386641454
Name:KANISTROS, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KANISTROS
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 1:1331 N ELM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-6302
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:4983 DELHI AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-5380
Practice Address - Country:US
Practice Address - Phone:513-347-7237
Practice Address - Fax:513-347-6567
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072707K2085R0202X
OH350727032085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200938470Medicaid
OH2034622Medicaid
4195864Medicare PIN
IN200938470Medicaid
P00473677Medicare PIN