Provider Demographics
NPI:1982131173
Name:MOUSTAKAS, DIMITRIOS (DPM)
Entity Type:Individual
Prefix:
First Name:DIMITRIOS
Middle Name:
Last Name:MOUSTAKAS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S. STATE ST
Mailing Address - Street 2:MAIL CODE 3055
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3530
Mailing Address - Country:US
Mailing Address - Phone:302-480-1688
Mailing Address - Fax:302-480-9807
Practice Address - Street 1:315 N CARTER RD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1282
Practice Address - Country:US
Practice Address - Phone:302-730-4366
Practice Address - Fax:302-730-0231
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE1-0000263213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program