Provider Demographics
NPI:1548353139
Name:TSAKOS, JOHN L (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:TSAKOS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19650 HARPER AVE.
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1968
Mailing Address - Country:US
Mailing Address - Phone:313-885-9496
Mailing Address - Fax:866-249-0054
Practice Address - Street 1:19650 HARPER AVE.
Practice Address - Street 2:SUITE 107
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1968
Practice Address - Country:US
Practice Address - Phone:313-885-9496
Practice Address - Fax:866-249-0054
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006714111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4877536Medicaid
MI4877536Medicaid
MI0Q25178Medicare ID - Type Unspecified