Provider Demographics
NPI:1679883748
Name:KODOR, DMITRI (PA-C)
Entity Type:Individual
Prefix:
First Name:DMITRI
Middle Name:
Last Name:KODOR
Suffix:
Gender:M
Credentials:PA-C
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 769609
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8224
Mailing Address - Country:US
Mailing Address - Phone:770-343-8760
Mailing Address - Fax:770-664-2101
Practice Address - Street 1:6330 PRIMROSE HILL CT
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092
Practice Address - Country:US
Practice Address - Phone:770-343-8760
Practice Address - Fax:770-664-2101
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA02933363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003142752AMedicaid
GA20297I5350Medicare PIN