Provider Demographics
NPI:1477646800
Name:ANTONIOU, DEMETRI (MD,DMD)
Entity Type:Individual
Prefix:DR
First Name:DEMETRI
Middle Name:
Last Name:ANTONIOU
Suffix:
Gender:M
Credentials:MD,DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SEWALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2641
Mailing Address - Country:US
Mailing Address - Phone:207-774-1775
Mailing Address - Fax:207-774-3126
Practice Address - Street 1:15 SEWALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2641
Practice Address - Country:US
Practice Address - Phone:207-774-1775
Practice Address - Fax:207-774-3126
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012240207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME118090000Medicaid
ME048010OtherANTHEM
MEC66253Medicare UPIN
ME118090000Medicaid