Provider Demographics
NPI:1952372963
Name:PATETSIOS, PETER (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:PATETSIOS
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NORTHERN BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5337
Mailing Address - Country:US
Mailing Address - Phone:516-570-6818
Mailing Address - Fax:516-466-6776
Practice Address - Street 1:900 NORTHERN BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5337
Practice Address - Country:US
Practice Address - Phone:516-570-6818
Practice Address - Fax:516-466-6776
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0170H1Medicare ID - Type Unspecified
H43958Medicare UPIN