Provider Demographics
NPI:1316009301
Name:KYDONIEUS, DEMETRIOS AGIS (DC)
Entity Type:Individual
Prefix:
First Name:DEMETRIOS
Middle Name:AGIS
Last Name:KYDONIEUS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8881 SEMINOLE TRL
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-3448
Mailing Address - Country:US
Mailing Address - Phone:434-481-2012
Mailing Address - Fax:
Practice Address - Street 1:435 BUCKHORN DR
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:NJ
Practice Address - Zip Code:07823-2710
Practice Address - Country:US
Practice Address - Phone:908-763-1178
Practice Address - Fax:908-750-4267
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00566000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ58-1893942OtherFEDERAL TAX ID
NJU17217Medicare UPIN
NJ042720Medicare ID - Type Unspecified