Provider Demographics
NPI:1760463087
Name:DEMETRIOU, ALEXANDRA (OTR L CHT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:DEMETRIOU
Suffix:
Gender:F
Credentials:OTR L CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 SUNRISE HWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-6027
Mailing Address - Country:US
Mailing Address - Phone:631-206-3130
Mailing Address - Fax:631-206-3148
Practice Address - Street 1:1555 SUNRISE HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6027
Practice Address - Country:US
Practice Address - Phone:631-206-3130
Practice Address - Fax:631-206-3148
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007141-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY200424663OtherTAX PAYER ID
NY200424663OtherTAX PAYER ID
5321480001Medicare NSC