Provider Demographics
NPI:1538274451
Name:DEDOPOULOS, SOPHY (NP)
Entity type:Individual
Prefix:
First Name:SOPHY
Middle Name:
Last Name:DEDOPOULOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 BRUSH HOLLOW RD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1740
Mailing Address - Country:US
Mailing Address - Phone:516-876-5555
Mailing Address - Fax:516-876-5539
Practice Address - Street 1:410 LAKEVILLE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1101
Practice Address - Country:US
Practice Address - Phone:516-465-5400
Practice Address - Fax:516-465-5454
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY497423 / 303779163W00000X
NY303779363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q38749Medicare UPIN
0991G1Medicare ID - Type Unspecified