Provider Demographics
NPI:1770610180
Name:KATSAROS, DEMETRIOS (MD)
Entity type:Individual
Prefix:
First Name:DEMETRIOS
Middle Name:
Last Name:KATSAROS
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 1:4503 THORNBURY DR E
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-0813
Mailing Address - Country:US
Mailing Address - Phone:219-549-0837
Mailing Address - Fax:219-548-0857
Practice Address - Street 1:7863 BROADWAY
Practice Address - Street 2:SUITE 135
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5553
Practice Address - Country:US
Practice Address - Phone:219-736-2047
Practice Address - Fax:219-736-2048
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049411174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200195840BMedicaid
IN000000080178OtherBLUE CROSS BLUE SHIELD
ING25543Medicare UPIN