Provider Demographics
NPI:1932163763
Name:DIMITRIOU, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:DIMITRIOU
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:18100 OAKWOOD BLVD
Practice Address - Street 2:SUITE 315
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4071
Practice Address - Country:US
Practice Address - Phone:313-271-0066
Practice Address - Fax:313-271-1047
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2015-12-02
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Provider Licenses
StateLicense IDTaxonomies
MI4301080784208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1716370002OtherCIGNA
MIH62344Medicare UPIN
MI136138OtherPRIORITY HEALTH
MI0219690005Medicare NSC
MI0E06273029Medicare PIN
MI340020150OtherRAILROAD MEDICARE
MI7013372OtherAETNA
MIH62344OtherHAP
MI4725848Medicaid