Provider Demographics
NPI:1649282815
Name:KANELLOPOULOS, ANASTASIOS JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:ANASTASIOS
Middle Name:JOHN
Last Name:KANELLOPOULOS
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 1:115 E 61ST ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-8183
Mailing Address - Country:US
Mailing Address - Phone:212-355-2215
Mailing Address - Fax:
Practice Address - Street 1:115 E 61ST ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-8183
Practice Address - Country:US
Practice Address - Phone:212-355-2215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189420207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01704521Medicaid
NY79I841Medicare ID - Type Unspecified
NY01704521Medicaid