Provider Demographics
NPI:1770513285
Name:GARDIANOS, PERICLES CHRISTO (DC)
Entity type:Individual
Prefix:DR
First Name:PERICLES
Middle Name:CHRISTO
Last Name:GARDIANOS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 DOLSONTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-4746
Mailing Address - Country:US
Mailing Address - Phone:845-342-1481
Mailing Address - Fax:
Practice Address - Street 1:1128 DOLSONTOWN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-4746
Practice Address - Country:US
Practice Address - Phone:845-342-1481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX-007623-1111N00000X
NJMC 04656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY108 6429OtherHIPPA EXTENSION CONF. NUM
NYX-007623-1OtherNY CHIRO. LICENSE #
NYX0-C27OtherEMPIRE BC/BS
NJMC 04656OtherNJ LICENSE #
NYP 2515 736OtherOXFORD NON-PAR. PROVIDER
NYC07623-4OtherNY WORKERS COMPENSATION N
NYX-007623-1OtherNY CHIRO. LICENSE #
NYU60784Medicare UPIN