Provider Demographics
NPI:1376599597
Name:DIMITRIS, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DIMITRIS
Suffix:
Gender:F
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:PO BOX 1649
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44309-1649
Mailing Address - Country:US
Mailing Address - Phone:330-864-8900
Mailing Address - Fax:330-869-8924
Practice Address - Street 1:525 E MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1619
Practice Address - Country:US
Practice Address - Phone:330-375-3369
Practice Address - Fax:330-375-3769
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082869207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2456908Medicaid
OH341779226003OtherMED MUTUAL OH 2 OF 3
OH341779226006OtherMED MUTUAL OF OH 3 OF 3
OH00000031642OtherANTHEM
OH61641OtherUNITED HEALTCARE
OH341779226002OtherMED MUTUAL OH 1 OF 3
OH4119832Medicare ID - Type Unspecified2 OF 3
OH341779226002OtherMED MUTUAL OH 1 OF 3
OH4119833Medicare ID - Type Unspecified3 OF 3
OH2456908Medicaid