Provider Demographics
NPI:1083111942
Name:DEDOUSIS, DEMITRIOS (MD)
Entity Type:Individual
Prefix:
First Name:DEMITRIOS
Middle Name:
Last Name:DEDOUSIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 N BROAD ST STE 226A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4105
Mailing Address - Country:US
Mailing Address - Phone:215-707-9837
Mailing Address - Fax:
Practice Address - Street 1:3509 N BROAD ST STE 226A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4105
Practice Address - Country:US
Practice Address - Phone:215-707-9837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program