Provider Demographics
NPI:1932104494
Name:RODITIS, NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:RODITIS
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 1:2318 31ST ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2892
Mailing Address - Country:US
Mailing Address - Phone:718-932-6000
Mailing Address - Fax:718-932-3194
Practice Address - Street 1:2318 31ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2892
Practice Address - Country:US
Practice Address - Phone:718-932-6000
Practice Address - Fax:718-932-3194
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2014-03-27
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NY186545207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01553662Medicaid
NY01HCARMedicare PIN
NY01553662Medicaid
NY05618GMedicare PIN