Provider Demographics
NPI:1528158250
Name:MIKELATOS, SPIROS H (MD)
Entity type:Individual
Prefix:DR
First Name:SPIROS
Middle Name:H
Last Name:MIKELATOS
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:COPA PACIFIC 23930 OCEAN AVENUE
Mailing Address - Street 2:211
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-663-5432
Mailing Address - Fax:
Practice Address - Street 1:4864 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029
Practice Address - Country:US
Practice Address - Phone:323-664-9000
Practice Address - Fax:323-664-9400
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21331174400000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty