Provider Demographics
NPI:1497180186
Name:KHORDOS, REGINA HANNA
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:HANNA
Last Name:KHORDOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 LORETTO ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-1920
Mailing Address - Country:US
Mailing Address - Phone:347-881-7787
Mailing Address - Fax:
Practice Address - Street 1:362 LORETTO ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10307-1920
Practice Address - Country:US
Practice Address - Phone:347-881-7787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY782552131174400000X
NY782551131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist