Provider Demographics
NPI:1477955649
Name:KONTOLEON, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:KONTOLEON
Suffix:
Gender:F
Credentials:
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 1957
Mailing Address - Street 2:2760 LIGHTHOUSE ROAD
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-0945
Mailing Address - Country:US
Mailing Address - Phone:646-409-5213
Mailing Address - Fax:
Practice Address - Street 1:2760 LIGHTHOUSE RD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-0945
Practice Address - Country:US
Practice Address - Phone:646-409-5213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY753552174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist