1326011180 NPI number — DR. JAMES L DEMETROULAKOS MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326011180 NPI number — DR. JAMES L DEMETROULAKOS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMETROULAKOS
Provider First Name:
JAMES
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326011180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 ENDICOTT ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DANVERS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01923-3623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-639-3055
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 ENDICOTT ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DANVERS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01923-3623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-745-6601
Provider Business Practice Location Address Fax Number:
978-624-4040
Provider Enumeration Date:
02/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  79502 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1000021 . This is a "UNITED HEALTH NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 19486 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2084343 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012294 . This is a "NEIGHBORHOOD HEALTH NUMBE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 040006919 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3129101 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 079502 . This is a "TUFTS NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 34544 . This is a "FALLON NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J30549 . This is a "BLUE SHIELD NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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