Provider Demographics
NPI:1497960124
Name:MITSOTAKIS, DEMETRA (MD)
Entity Type:Individual
Prefix:
First Name:DEMETRA
Middle Name:
Last Name:MITSOTAKIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 85TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-4208
Mailing Address - Country:US
Mailing Address - Phone:718-759-1472
Mailing Address - Fax:
Practice Address - Street 1:1407 W 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4802
Practice Address - Country:US
Practice Address - Phone:718-256-1057
Practice Address - Fax:718-256-4912
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230996208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics