Provider Demographics
NPI:1184718371
Name:DIAMANTOPOULOS, VASILIOS THEODOROS (MD)
Entity type:Individual
Prefix:DR
First Name:VASILIOS
Middle Name:THEODOROS
Last Name:DIAMANTOPOULOS
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 1:1018 BOYNTON AVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-1692
Mailing Address - Country:US
Mailing Address - Phone:908-518-1593
Mailing Address - Fax:973-989-3092
Practice Address - Street 1:1018 BOYNTON AVE
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1692
Practice Address - Country:US
Practice Address - Phone:908-518-1593
Practice Address - Fax:973-989-3092
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06113100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7046502Medicaid
NJ025234Medicare ID - Type Unspecified
NJ7046502Medicaid
NJ025236Medicare ID - Type Unspecified
739426Medicare PIN