Provider Demographics
NPI:1629109012
Name:MAVROMATIS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MAVROMATIS
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 1:131 HIGHMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-1508
Mailing Address - Country:US
Mailing Address - Phone:845-358-7219
Mailing Address - Fax:845-358-7234
Practice Address - Street 1:131 HIGHMOUNT AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1508
Practice Address - Country:US
Practice Address - Phone:845-358-7219
Practice Address - Fax:845-358-7234
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1367332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB16077Medicare UPIN