Provider Demographics
NPI:1851327522
Name:DIMITRIADES, DIMITRIOS J (MD)
Entity Type:Individual
Prefix:DR
First Name:DIMITRIOS
Middle Name:J
Last Name:DIMITRIADES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DIMITRIOS
Other - Middle Name:J
Other - Last Name:DIMITRIADES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-865-1453
Mailing Address - Fax:228-868-8504
Practice Address - Street 1:394 COURTHOUSE RD
Practice Address - Street 2:SUITE A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1865
Practice Address - Country:US
Practice Address - Phone:228-896-4417
Practice Address - Fax:228-604-0121
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119666Medicaid
MS5057532OtherAETNA
MS080119197OtherRAILROAD MEDICARE
MS$$$$$$$$$GOtherBCBS
MS$$$$$$$$$EOtherBCBS
MS5057532OtherAETNA
MS$$$$$$$$$GOtherBCBS
MS5057532OtherAETNA
MS110001066Medicare ID - Type Unspecified