Provider Demographics
NPI:1417162546
Name:VLANTIS, NICKOLAS GEORGE (OD)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:GEORGE
Last Name:VLANTIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16005 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3938
Mailing Address - Country:US
Mailing Address - Phone:718-357-5458
Mailing Address - Fax:
Practice Address - Street 1:5572 BROADWAY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5216
Practice Address - Country:US
Practice Address - Phone:718-884-4297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005473-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist