Provider Demographics
NPI:1659301620
Name:DEMETRIADES, DEMETRIOS (MD)
Entity Type:Individual
Prefix:
First Name:DEMETRIOS
Middle Name:
Last Name:DEMETRIADES
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 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-409-7761
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN PABLO ST FL 7
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-409-7761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG534042086S0102X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A534040OtherINDIVIDUAL BLUE SHIELD
CA020023697OtherMEDICARE RAILROAD
CA00A534040Medicaid
CA00A534040OtherINDIVIDUAL BLUE SHIELD
CAF55295Medicare UPIN
CABM487ZMedicare PIN