Provider Demographics
NPI:1598863458
Name:FILLOS, TRIANTAFILLOS JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:TRIANTAFILLOS
Middle Name:JOHN
Last Name:FILLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112
Mailing Address - Street 2:BLDG 4
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:4564 FRANCIS LEWIS BLVD STE 202
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3085
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-509-6559
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237195207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400012605Medicare PIN
P00735221Medicare PIN
NYA400013695Medicare PIN