Provider Demographics
NPI:1518453398
Name:VOURDERIS, NICHOLAS (PT,DPT)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:VOURDERIS
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 WOODROW RD STE 321
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1725
Mailing Address - Country:US
Mailing Address - Phone:718-844-5350
Mailing Address - Fax:718-966-0005
Practice Address - Street 1:9920 4TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-8379
Practice Address - Country:US
Practice Address - Phone:718-238-9873
Practice Address - Fax:718-238-9754
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist