Individual
MR. DIMITRIOS FANTAKOS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
21426 41ST AVE, BAYSIDE, NY 11361-2159
(718) 631-1110
(718) 631-1314
Mailing address
21426 41ST AVE, BAYSIDE, NY 11361-2159
(718) 631-1110
(718) 631-1314
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Enumeration date
07/24/2012
Last updated
07/24/2012
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