Provider Demographics
NPI:1487000410
Name:DRAKONTAIDIS, ALEXANDER
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:DRAKONTAIDIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-2110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 WILSON AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-2110
Practice Address - Country:US
Practice Address - Phone:845-399-4147
Practice Address - Fax:845-399-4147
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094842-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1255606406Medicaid
NY1255606406Medicare NSC