Provider Demographics
NPI:1396840542
Name:DRITSAS, ERIC RUSSEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:RUSSEL
Last Name:DRITSAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1069
Mailing Address - Country:US
Mailing Address - Phone:630-725-2700
Mailing Address - Fax:630-725-2783
Practice Address - Street 1:8128 PARK LANE
Practice Address - Street 2:SUITE 130
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5908
Practice Address - Country:US
Practice Address - Phone:214-361-1222
Practice Address - Fax:214-361-1205
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77233208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500612383Medicaid
H67950Medicare UPIN
TXTXB156437Medicare PIN
TXTXB155426Medicare PIN
ORR148859Medicare PIN
OR500612383Medicaid
TX292521Medicare PIN
TX261521YMZSMedicare PIN
TX261521YSWXMedicare PIN