Basic Information
| Provider Information | |||||||||
| NPI: | 1417154733 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAKOULIDES | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314225371 | ||||||||
| FaxNumber: | 6314225371 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314225371 | ||||||||
| FaxNumber: | 6314225371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | RT-1751 | NH | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 275213 | NY | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 04022455 | 05 | NY | MEDICAID |