Provider Demographics
NPI:1801957139
Name:XISTRIS, EVANGELOS DEMETRIOS (MD)
Entity type:Individual
Prefix:
First Name:EVANGELOS
Middle Name:DEMETRIOS
Last Name:XISTRIS
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 1:29 HOSPITAL PLAZA
Mailing Address - Street 2:SUITE 602
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3602
Mailing Address - Country:US
Mailing Address - Phone:203-276-4464
Mailing Address - Fax:203-276-4468
Practice Address - Street 1:29 HOSPITAL PLAZA
Practice Address - Street 2:SUITE 602
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3602
Practice Address - Country:US
Practice Address - Phone:203-276-4464
Practice Address - Fax:203-276-4468
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT201442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB-83516Medicare UPIN