Provider Demographics
NPI:1578551875
Name:HERODOTOU, DEMETRIOS (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMETRIOS
Middle Name:
Last Name:HERODOTOU
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:910-721-4230
Mailing Address - Fax:910-721-4239
Practice Address - Street 1:512 VILLAGE RD STE 205
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-3409
Practice Address - Country:US
Practice Address - Phone:910-721-4230
Practice Address - Fax:910-721-4239
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51100207R00000X, 207RE0101X
NC2021-02512207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200164530Medicaid
000000492811OtherANTHEM
IN200164530Medicaid
000000492811OtherANTHEM