Provider Demographics
NPI:1073666269
Name:DIMITRIOS P BOUSOUNIS MD
Entity Type:Organization
Organization Name:DIMITRIOS P BOUSOUNIS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIMITRIOS
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOUSOUNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-964-8450
Mailing Address - Street 1:200 W SILVER SPRING DR STE 255
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5058
Mailing Address - Country:US
Mailing Address - Phone:414-964-8450
Mailing Address - Fax:414-964-8451
Practice Address - Street 1:200 W SILVER SPRING DR STE 255
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5058
Practice Address - Country:US
Practice Address - Phone:414-964-8450
Practice Address - Fax:414-964-8451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27172261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty