Provider Demographics
NPI:1407177207
Name:DIMITRO, ANDREW DIMOS (PT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:DIMOS
Last Name:DIMITRO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1448
Mailing Address - Country:US
Mailing Address - Phone:304-395-5635
Mailing Address - Fax:
Practice Address - Street 1:810 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1448
Practice Address - Country:US
Practice Address - Phone:304-395-5635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0995174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist