Provider Demographics
NPI:1467624064
Name:MITSINIKOS, THEOFANIS (DO)
Entity Type:Individual
Prefix:DR
First Name:THEOFANIS
Middle Name:
Last Name:MITSINIKOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NESCONSET HWY
Mailing Address - Street 2:BLDG 3C
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-751-2400
Mailing Address - Fax:631-751-8323
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:BLDG 3C
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-751-2400
Practice Address - Fax:631-751-8323
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-24
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY235458207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism