Provider Demographics
NPI:1063414852
Name:VLATTAS, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:VLATTAS
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 1:21316 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2045
Mailing Address - Country:US
Mailing Address - Phone:718-229-7800
Mailing Address - Fax:718-279-7470
Practice Address - Street 1:21316 39TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2045
Practice Address - Country:US
Practice Address - Phone:718-229-7800
Practice Address - Fax:718-279-7470
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1956842081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY195684-6OtherLICENSE
NYG03614Medicare UPIN
NY05862PMedicare PIN