Basic Information
| Provider Information | |||||||||
| NPI: | 1841717618 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGE KAKOULIDES MD PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 380 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314225371 | ||||||||
| FaxNumber: | 6318938012 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314225371 | ||||||||
| FaxNumber: | 6318938012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KAKOULIDES | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6314225371 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 275213 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.