Provider Demographics
NPI:1720342900
Name:DEMETRIOS, MEENA (MD)
Entity Type:Individual
Prefix:DR
First Name:MEENA
Middle Name:
Last Name:DEMETRIOS
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 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6017
Mailing Address - Fax:904-450-6041
Practice Address - Street 1:4203 BELFORT RD STE 204
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1463
Practice Address - Country:US
Practice Address - Phone:904-296-5688
Practice Address - Fax:904-296-5699
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA077782207V00000X
FLME146669207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08117262OtherAMERIGROUP
FL107709000Medicaid