Provider Demographics
NPI:1366908139
Name:ANTZOULATOS, KATHERINE (DPM, RD, CDN)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ANTZOULATOS
Suffix:
Gender:F
Credentials:DPM, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 150TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1653
Mailing Address - Country:US
Mailing Address - Phone:347-642-0315
Mailing Address - Fax:
Practice Address - Street 1:915 150TH ST
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1653
Practice Address - Country:US
Practice Address - Phone:347-642-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1000889133V00000X
NYN004198213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered