Provider Demographics
NPI:1588795967
Name:KOKKALIAS, MARIGO (DPT)
Entity Type:Individual
Prefix:
First Name:MARIGO
Middle Name:
Last Name:KOKKALIAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 WHEATLEY PLZ
Mailing Address - Street 2:
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548-1338
Mailing Address - Country:US
Mailing Address - Phone:516-621-2267
Mailing Address - Fax:516-621-2268
Practice Address - Street 1:340 WHEATLEY PLZ
Practice Address - Street 2:
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1338
Practice Address - Country:US
Practice Address - Phone:516-621-2267
Practice Address - Fax:516-621-2268
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026736-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQOWDP1Medicare ID - Type UnspecifiedGROUP