Provider Demographics
NPI:1093786725
Name:DEMOS AGIOMAVRITIS MD PC
Entity Type:Organization
Organization Name:DEMOS AGIOMAVRITIS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEMOSTHENES
Authorized Official - Middle Name:K
Authorized Official - Last Name:AGIOMAVRITIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-770-8002
Mailing Address - Street 1:385 GROVE ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3924
Mailing Address - Country:US
Mailing Address - Phone:508-770-8002
Mailing Address - Fax:508-770-8006
Practice Address - Street 1:385 GROVE ST
Practice Address - Street 2:SUITE 120
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3924
Practice Address - Country:US
Practice Address - Phone:508-770-8002
Practice Address - Fax:508-770-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47165207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
61250OtherHARVARD PILGRIM
9065240OtherPRIVATE HEALTH CARE
20787175OtherTAX ID
26373OtherFALLON
701827OtherTUFTS
999969OtherNETWORK HEALTH
MA9751530Medicaid
N01922OtherBLUE CROSS INDIVIDUAL
M18983OtherBCBS
999969OtherNETWORK HEALTH
=========OtherCHAMPUS
M18983OtherBCBS
MA9751530Medicaid
MA9751530Medicaid
N01922OtherBLUE CROSS INDIVIDUAL
=========OtherCIGNA