Provider Demographics
NPI:1538340211
Name:NISSIRIOS, FOTINI
Entity type:Individual
Prefix:
First Name:FOTINI
Middle Name:
Last Name:NISSIRIOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FAYE
Other - Middle Name:
Other - Last Name:PERDIKOLOGOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:85 DOVER RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15365 CROSS ISLAND PKWY
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-2648
Practice Address - Country:US
Practice Address - Phone:718-767-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050449-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00268066Medicaid