Provider Demographics
NPI:1760415384
Name:LADDIS, DIMITRI (MD)
Entity Type:Individual
Prefix:DR
First Name:DIMITRI
Middle Name:
Last Name:LADDIS
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 1:31 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:PIERMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10968-1207
Mailing Address - Country:US
Mailing Address - Phone:917-974-7279
Mailing Address - Fax:
Practice Address - Street 1:481 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-4313
Practice Address - Country:US
Practice Address - Phone:201-875-2454
Practice Address - Fax:732-707-5001
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2023-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2288751208000000X
NY2288752080P0204X
NJ25MA105575002080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA10557500OtherNEW JERSEY LICENSE
NY02461127Medicaid
NY02461127Medicaid