Provider Demographics
NPI:1609843937
Name:DEMITRACK, JAMES GUS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GUS
Last Name:DEMITRACK
Suffix:JR
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:PSC 561 BOX 1877
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-0019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NBHC IWAKUNI, BLDG 110, MCAS IWAKUNI
Practice Address - Street 2:1 MISUMI MACHI
Practice Address - City:IWAKUNI
Practice Address - State:YAMAGUCHI
Practice Address - Zip Code:7400025
Practice Address - Country:JP
Practice Address - Phone:315-255-8298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238544208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics