Provider Demographics
NPI:1114920790
Name:DERMARKAR, GEORGE ARCHAK (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ARCHAK
Last Name:DERMARKAR
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 1:401 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5963
Mailing Address - Country:US
Mailing Address - Phone:813-684-2339
Mailing Address - Fax:813-684-1726
Practice Address - Street 1:401 VONDERBURG DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5963
Practice Address - Country:US
Practice Address - Phone:813-684-2339
Practice Address - Fax:813-684-1726
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 62547174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL203968OtherAVMED
FL2213854OtherAETNA
FL17796OtherBCBS
FL212993OtherWELLCARE
FL0412825OtherCIGNA
FL2213854OtherAETNA
FL17796QMedicare ID - Type UnspecifiedFHOC MEDICARE GROUP INDIV
FL0412825OtherCIGNA
FL17796OtherBCBS