Provider Demographics
NPI:1669653812
Name:MENEGOS, DEMETRIOS (DO)
Entity Type:Individual
Prefix:DR
First Name:DEMETRIOS
Middle Name:
Last Name:MENEGOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LANCASTER AVE
Mailing Address - Street 2:SUITE 256 LANKENAU MOB EAST
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:610-649-8055
Mailing Address - Fax:610-649-4367
Practice Address - Street 1:3039 FOULK RD
Practice Address - Street 2:
Practice Address - City:GARNET VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19060-1701
Practice Address - Country:US
Practice Address - Phone:610-361-0070
Practice Address - Fax:610-361-0071
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014890207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA175959ZJJJMedicare PIN