Provider Demographics
NPI:1821104498
Name:MOUHTOURI DIMOPOULOS, POLYXENI (MD)
Entity Type:Individual
Prefix:
First Name:POLYXENI
Middle Name:
Last Name:MOUHTOURI DIMOPOULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:POLYXENI
Other - Middle Name:
Other - Last Name:DIMOPOULOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2240 NORTH FOREST ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-639-4034
Mailing Address - Fax:716-929-8940
Practice Address - Street 1:2240 NORTH FOREST ROAD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-639-4034
Practice Address - Fax:716-929-8940
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265937207V00000X, 207V00000X
FLME114733207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400154504Medicare PIN
NYJ400073301/GRPBA0017Medicare PIN