Provider Demographics
NPI:1750479358
Name:VALLIANATOS, AGATHI (MD)
Entity type:Individual
Prefix:DR
First Name:AGATHI
Middle Name:
Last Name:VALLIANATOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AGATHI
Other - Middle Name:
Other - Last Name:VILLIANATOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1456 FULTON ST
Mailing Address - Street 2:BEDFORD STUYVESANT FAMILY HEALTH CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2505
Mailing Address - Country:US
Mailing Address - Phone:718-636-4500
Mailing Address - Fax:347-296-8337
Practice Address - Street 1:1456 FULTON ST
Practice Address - Street 2:BEDFORD STUYVESANT FAMILY HEALTH CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2505
Practice Address - Country:US
Practice Address - Phone:718-636-4500
Practice Address - Fax:347-296-8337
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233651208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02638140Medicaid