Provider Demographics
NPI:1861929861
Name:THEOFANIS MITSINIKOS, DO, PC
Entity type:Organization
Organization Name:THEOFANIS MITSINIKOS, DO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEOFANIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MITSINIKOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-751-2400
Mailing Address - Street 1:2500 NESCONSET HWY BLDG 3C
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 NESCONSET HWY BLDG 3C
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2551
Practice Address - Country:US
Practice Address - Phone:631-751-2400
Practice Address - Fax:631-751-8323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235458207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty