Provider Demographics
NPI:1104451525
Name:DR PAUL POULAKOS DO, LLC
Entity type:Organization
Organization Name:DR PAUL POULAKOS DO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:POULAKOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:917-275-3625
Mailing Address - Street 1:412 6TH AVENUE
Mailing Address - Street 2:FLOOR 7, SUITE 702
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-4918
Mailing Address - Country:US
Mailing Address - Phone:917-275-3625
Mailing Address - Fax:
Practice Address - Street 1:412 6TH AVENUE
Practice Address - Street 2:FLOOR 7, SUITE 702
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4918
Practice Address - Country:US
Practice Address - Phone:917-275-3625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-05
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center