Basic Information
| Provider Information | |||||||||
| NPI: | 1083026868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANAROGLOU | ||||||||
| FirstName: | ANDRONIKI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KANAROGLOU | ||||||||
| OtherFirstName: | NIKI | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1300 SAWGRASS CORPORATE PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8555275510 | ||||||||
| Practice Location | |||||||||
| Address1: | 10301 HAGEN RANCH RD | ||||||||
| Address2: | SUITE C130 | ||||||||
| City: | BOYTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617367313 | ||||||||
| FaxNumber: | 5617362309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2014 | ||||||||
| LastUpdateDate: | 03/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | FL | N | Other Service Providers | Specialist | 2088P0231X | ME120235 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | 011989900 | 05 | FL | MEDICAID |