Provider Demographics
NPI:1386850691
Name:AGIOMAVRITIS, DEMOSTHENES (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMOSTHENES
Middle Name:
Last Name:AGIOMAVRITIS
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:367 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2323
Practice Address - Country:US
Practice Address - Phone:508-334-1443
Practice Address - Fax:508-334-1448
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47165207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2078767Medicaid
MA701827OtherTUFTS
MAN01922OtherBLUE CROSS
MA202787175OtherCHAMPUS
MA202787175OtherUNITED HEALTHCARE
MA9751530Medicaid
MAM18983OtherBLUE CROSS
MA202787175OtherCIGNA
MA202787175OtherGREAT WEST
MA202787175OtherAETNA
MA26373OtherFALLON
MA999969OtherNETWORK HEALTH
MA202787175OtherTAX ID
MA202787175OtherNETWORK HEALTH
MA61250OtherHARVARD PILGRIM
MA61250OtherHARVARD PILGRIM
MA202787175OtherUNITED HEALTHCARE
MAN01922Medicare ID - Type Unspecified
MADE2948Medicare ID - Type UnspecifiedMEDICARE RAILROAD
MAP00283683Medicare ID - Type UnspecifiedMEDICARE RAILROAD