Provider Demographics
NPI:1518020429
Name:DIMITRIS, KIRK D (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:D
Last Name:DIMITRIS
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 28900
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54324-0900
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:1160 KEPLER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8321
Practice Address - Country:US
Practice Address - Phone:920-288-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52604-020207X00000X
FLME100953207X00000X
OH35.085490207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI390806395003OtherCHAMPUS
WI1518020429OtherBCBS
WI207X00000XMedicaid
WI207X00000XMedicaid