Provider Demographics
NPI:1578015228
Name:SIBOS, DEMITRA
Entity Type:Individual
Prefix:
First Name:DEMITRA
Middle Name:
Last Name:SIBOS
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 1:3517 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4405
Mailing Address - Country:US
Mailing Address - Phone:646-496-6640
Mailing Address - Fax:
Practice Address - Street 1:535 8TH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-4305
Practice Address - Country:US
Practice Address - Phone:212-787-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1061628161174400000X
NY1061477161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist