Provider Demographics
NPI:1225272412
Name:DIMITRAKOFF, JORDAN D (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:D
Last Name:DIMITRAKOFF
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:JORDAN
Other - Middle Name:D
Other - Last Name:DIMITRAKOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:330 BROOKLINE AVE KS-316
Mailing Address - Street 2:BETH ISRAEL DECONESS MEDICAL CENTER
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-667-2051
Mailing Address - Fax:617-249-2035
Practice Address - Street 1:330 BROOKLINE AVE KS-316
Practice Address - Street 2:BETH ISRAEL DECONESS MEDICAL CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-667-2051
Practice Address - Fax:617-249-2035
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPENDING207R00000X, 207RA0000X, 208800000X
MA244988207R00000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208800000XAllopathic & Osteopathic PhysiciansUrology