Provider Demographics
NPI:1700373669
Name:TSALICKIS, DIMITRI MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:DIMITRI
Middle Name:MICHAEL
Last Name:TSALICKIS
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 1:11178 STATE ROAD 54 STE A
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2266
Mailing Address - Country:US
Mailing Address - Phone:727-372-4200
Mailing Address - Fax:
Practice Address - Street 1:11178 STATE ROAD 54 STE A
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-2266
Practice Address - Country:US
Practice Address - Phone:727-372-4200
Practice Address - Fax:727-333-6371
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS17144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111342800Medicaid