Provider Demographics
NPI:1306121504
Name:GERIATRICS AND LONGEVITY TREATMENT SPECIALIST, PC
Entity type:Organization
Organization Name:GERIATRICS AND LONGEVITY TREATMENT SPECIALIST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEFANOS
Authorized Official - Middle Name:G
Authorized Official - Last Name:PANTAGIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-663-7375
Mailing Address - Street 1:810 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-4847
Mailing Address - Country:US
Mailing Address - Phone:201-663-7375
Mailing Address - Fax:
Practice Address - Street 1:810 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-4847
Practice Address - Country:US
Practice Address - Phone:201-663-7375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty