Provider Demographics
NPI:1881691517
Name:FOTIADIS, GEORGE N (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:N
Last Name:FOTIADIS
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 1:827 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50213-1666
Mailing Address - Country:US
Mailing Address - Phone:641-342-2128
Mailing Address - Fax:641-342-3179
Practice Address - Street 1:827 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IA
Practice Address - Zip Code:50213-1666
Practice Address - Country:US
Practice Address - Phone:641-342-2128
Practice Address - Fax:641-342-3179
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1024422Medicaid
IA1881691517Medicaid
IA080063418OtherRR MEDICARE
IA1024422Medicaid
A03225Medicare UPIN