Provider Demographics
NPI:1164467056
Name:SIRAKOFF, DIMITRI (DO)
Entity Type:Individual
Prefix:
First Name:DIMITRI
Middle Name:
Last Name:SIRAKOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 E 17TH ST
Mailing Address - Street 2:STE 204
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2641
Mailing Address - Country:US
Mailing Address - Phone:714-835-3500
Mailing Address - Fax:714-835-4619
Practice Address - Street 1:1206 E 17TH ST
Practice Address - Street 2:STE 204
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2641
Practice Address - Country:US
Practice Address - Phone:714-835-3500
Practice Address - Fax:714-835-4619
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0SD0899486OtherCLIA ID
CA00AX55521Medicaid
CA00AX55521Medicaid
CA00AX55521Medicaid