Provider Demographics
NPI:1457791063
Name:VAVILIS, GEORGE NICHOLAS (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:NICHOLAS
Last Name:VAVILIS
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 1:501A W MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-8308
Mailing Address - Country:US
Mailing Address - Phone:631-587-0574
Mailing Address - Fax:631-422-1055
Practice Address - Street 1:501A W MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-8308
Practice Address - Country:US
Practice Address - Phone:631-587-0574
Practice Address - Fax:631-422-1055
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289680207RE0101X, 207RE0101X
KY48953207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1457791063Medicaid