Provider Demographics
NPI:1508830191
Name:MITSOGLOU, GEORGE M (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:M
Last Name:MITSOGLOU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1815
Mailing Address - Country:US
Mailing Address - Phone:518-563-9258
Mailing Address - Fax:
Practice Address - Street 1:292 CORNELIA ST
Practice Address - Street 2:BUILDING 2
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2303
Practice Address - Country:US
Practice Address - Phone:518-563-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYU005623152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02301848Medicaid
NY55381BMedicare ID - Type Unspecified
NYU58175Medicare UPIN