Provider Demographics
NPI:1720364367
Name:KONOFAOS, PETROS (MD, PHD)
Entity Type:Individual
Prefix:
First Name:PETROS
Middle Name:
Last Name:KONOFAOS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650859
Mailing Address - Street 2:DEPT. 710
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0859
Mailing Address - Country:US
Mailing Address - Phone:409-772-2222
Mailing Address - Fax:
Practice Address - Street 1:1005 HARBORSIDE DR
Practice Address - Street 2:5TH FLOOR
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0001
Practice Address - Country:US
Practice Address - Phone:409-772-8115
Practice Address - Fax:409-772-1872
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU1064208200000X, 208600000X, 2086S0122X
TNMD50989208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08231501Medicaid
GA003180136AMedicaid
TNQ007443Medicaid
MO1720364367Medicaid
AL177445Medicaid
AR204025001Medicaid