Provider Demographics
NPI:1235351768
Name:DIMITRI SIRAKOFF DO INC
Entity Type:Organization
Organization Name:DIMITRI SIRAKOFF DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIMITRI
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRAKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-835-3500
Mailing Address - Street 1:1206 E 17TH STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2341
Mailing Address - Country:US
Mailing Address - Phone:714-835-3500
Mailing Address - Fax:714-835-4619
Practice Address - Street 1:1206 E 17TH STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2341
Practice Address - Country:US
Practice Address - Phone:714-835-3500
Practice Address - Fax:714-835-4619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX55521Medicaid
CABS1435937OtherDEA
CAXS1435937OtherDEA
CA00AX55521Medicaid
CAXS1435937OtherDEA