Provider Demographics
NPI:1336375500
Name:DICKS, DEMETRIUS LEUTREL (MD)
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:LEUTREL
Last Name:DICKS
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:PO BOX 3157
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3157
Mailing Address - Country:US
Mailing Address - Phone:770-405-2976
Mailing Address - Fax:
Practice Address - Street 1:790 CHURCH ST NE STE 400
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8957
Practice Address - Country:US
Practice Address - Phone:770-405-2976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0780172085R0202X
WA600793092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology