Provider Demographics
NPI:1659489284
Name:SOULTANAKIS, EMMANUEL NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:NICHOLAS
Last Name:SOULTANAKIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:102 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9692
Practice Address - Country:US
Practice Address - Phone:207-883-0069
Practice Address - Fax:207-883-0999
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010087207V00000X, 207VX0201X
MEMD19505207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN2415Medicaid
NY02118770Medicaid
ME003095701Medicare PIN
ME003095702Medicare PIN
NY02118770Medicaid
VT0VN2415Medicaid