Provider Demographics
NPI:1629569504
Name:MACRIS, DIMITRI GIDDINGS
Entity Type:Individual
Prefix:
First Name:DIMITRI
Middle Name:GIDDINGS
Last Name:MACRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 POTRERO AVE # 6B
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:675 18TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-4200
Practice Address - Country:US
Practice Address - Phone:415-476-7000
Practice Address - Fax:415-476-7320
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1739952084P0800X, 2084P0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101Y00000XBehavioral Health & Social Service ProvidersCounselor