Provider Demographics
NPI:1629969514
Name:KOTSOVOLOS, PETER E
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:KOTSOVOLOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-2332
Mailing Address - Country:US
Mailing Address - Phone:631-626-6322
Mailing Address - Fax:
Practice Address - Street 1:888 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4914
Practice Address - Country:US
Practice Address - Phone:516-719-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-10
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY752812163WC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine