Provider Demographics
NPI:1396485264
Name:XENOPHONTOS, GEORGIA THEODORA
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:THEODORA
Last Name:XENOPHONTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3039
Mailing Address - Country:US
Mailing Address - Phone:515-316-4545
Mailing Address - Fax:515-365-7111
Practice Address - Street 1:1165 NORTHERN BLVD STE 301
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3048
Practice Address - Country:US
Practice Address - Phone:516-365-4545
Practice Address - Fax:516-365-7111
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007466213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery