Provider Demographics
NPI:1659423960
Name:MERTSARIS, NICOLA HIPPOCRATES (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:HIPPOCRATES
Last Name:MERTSARIS
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 16 31 AVENUE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103
Mailing Address - Country:US
Mailing Address - Phone:718-626-7029
Mailing Address - Fax:718-267-9003
Practice Address - Street 1:40 16 31 AVENUE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103
Practice Address - Country:US
Practice Address - Phone:718-626-7029
Practice Address - Fax:718-267-9003
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133950207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003437427Medicaid
NY003437427Medicaid