Provider Demographics
NPI:1558658989
Name:DEMETRIUS C ZODIATIS,MD.PC.
Entity Type:Organization
Organization Name:DEMETRIUS C ZODIATIS,MD.PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:DEMETRIUS
Authorized Official - Middle Name:CHRISTOS
Authorized Official - Last Name:ZODIATIS
Authorized Official - Suffix:I
Authorized Official - Credentials:MD,FACP
Authorized Official - Phone:631-751-7588
Mailing Address - Street 1:1388 STONY BROOK RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2205
Mailing Address - Country:US
Mailing Address - Phone:631-751-7588
Mailing Address - Fax:631-689-3665
Practice Address - Street 1:1388 STONY BROOK RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2205
Practice Address - Country:US
Practice Address - Phone:631-751-7588
Practice Address - Fax:631-689-3665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
119465261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY281341Medicare PIN