Basic Information
| Provider Information | |||||||||
| NPI: | 1265497390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOURTZIKOS | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 EAST SUNRISE HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312257200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 150 EAST SUNRISE HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312257200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 12/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | 228831 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02424000 | 05 | NY | MEDICAID |