Provider Demographics
NPI:1275575078
Name:CHAMCHAD, DMITRI (MD)
Entity Type:Individual
Prefix:DR
First Name:DMITRI
Middle Name:
Last Name:CHAMCHAD
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 1:744 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1909
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:610 W GERMANTOWN PIKE STE 150
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1062
Practice Address - Country:US
Practice Address - Phone:610-525-4966
Practice Address - Fax:844-823-2626
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD418808174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist