Provider Demographics
NPI:1609834274
Name:YAGDJIS, DIMITRI PETER (CPO)
Entity Type:Individual
Prefix:MR
First Name:DIMITRI
Middle Name:PETER
Last Name:YAGDJIS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8629 KELVIN AVE
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-1254
Mailing Address - Country:US
Mailing Address - Phone:818-321-6829
Mailing Address - Fax:
Practice Address - Street 1:16122 COVELLO ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-2910
Practice Address - Country:US
Practice Address - Phone:818-988-5414
Practice Address - Fax:818-988-5415
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO023711744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management