Provider Demographics
NPI:1457326126
Name:MTANOS, GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:MTANOS
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 1:5794 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1845
Mailing Address - Country:US
Mailing Address - Phone:315-422-1513
Mailing Address - Fax:315-422-5890
Practice Address - Street 1:5794 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1845
Practice Address - Country:US
Practice Address - Phone:315-422-1513
Practice Address - Fax:315-422-5890
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206080207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01624973Medicaid
G15952Medicare UPIN
NYRA2078Medicare ID - Type Unspecified