Provider Demographics
NPI:1376632018
Name:DIMITROFF, JAMES W (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:DIMITROFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-543-5200
Mailing Address - Fax:314-543-5219
Practice Address - Street 1:3555 SUNSET OFFICE DR STE 107
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1045
Practice Address - Country:US
Practice Address - Phone:314-543-5200
Practice Address - Fax:314-543-5219
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO105556207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206981201Medicaid
MO004011267Medicare ID - Type Unspecified
MO206981201Medicaid
MO124510069Medicare PIN