Provider Demographics
NPI:1326056094
Name:FANOPOULOS, DIMITRIOS I (MD MPH)
Entity Type:Individual
Prefix:
First Name:DIMITRIOS
Middle Name:I
Last Name:FANOPOULOS
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC.
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-364-2705
Practice Address - Street 1:1905 E. HUEBBE PARKWAY
Practice Address - Street 2:BELOIT HEALTH SYSTEM INC.
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1842
Practice Address - Country:US
Practice Address - Phone:608-364-2200
Practice Address - Fax:608-364-2705
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41141020207RR0500X
IL036-093988207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
12205OtherDEAN HEALTH PLAN HMO
WI1326056094Medicaid
G96605Medicare UPIN
WI543300021Medicare PIN