Provider Demographics
NPI:1760712814
Name:BACOS, DIMITRI (MD)
Entity Type:Individual
Prefix:DR
First Name:DIMITRI
Middle Name:
Last Name:BACOS
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 1:1080 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1966
Mailing Address - Country:US
Mailing Address - Phone:831-454-4296
Mailing Address - Fax:
Practice Address - Street 1:1080 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1966
Practice Address - Country:US
Practice Address - Phone:831-454-4296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1101602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91891ZOtherSANTA CRUZ COUNTY, CALIFORNIA MEDICARE GROUP PTAN #
CAZZZ91892ZOtherSANTA CRUZ COUNTY, CALIFORNIA MEDICARE GROUP PTAN #
CAFHC 700 44FOtherSANTA CRUZ COUNTY, CALIFORNIA MEDI-CAL GROUP ID
CAFHC70042FOtherSANTA CRUZ COUNTY, CALIFORNIA MEDI-CAL GROUP ID