Provider Demographics
NPI:1477674562
Name:SPANIOLAS, KONSTANTINOS (MD)
Entity Type:Individual
Prefix:
First Name:KONSTANTINOS
Middle Name:
Last Name:SPANIOLAS
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HSC T19 020
Practice Address - Street 2:STONY BROOK MEDICINE
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8191
Practice Address - Country:US
Practice Address - Phone:631-444-2274
Practice Address - Fax:631-444-6176
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH15643208600000X
NC2013-01267208600000X
NY286029208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1477674562Medicaid
NC180Y2OtherBCBS NC
NC180Y2OtherBCBS NC