Provider Demographics
NPI:1457335762
Name:KATSIKAS, DEMETRIOS A (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMETRIOS
Middle Name:A
Last Name:KATSIKAS
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 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 375
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8635
Mailing Address - Country:US
Mailing Address - Phone:314-567-6071
Mailing Address - Fax:314-567-7961
Practice Address - Street 1:6812 STATE ROUTE 162 STE 200
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8562
Practice Address - Country:US
Practice Address - Phone:618-288-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101727208800000X
MO108181208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205382302Medicaid
ILL85766Medicare PIN