1528032786 NPI number — DR. DIMITRIOS PANAGOPOULOS DPM

Table of content: DR. DIMITRIOS PANAGOPOULOS DPM (NPI 1528032786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528032786 NPI number — DR. DIMITRIOS PANAGOPOULOS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANAGOPOULOS
Provider First Name:
DIMITRIOS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1528032786
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24025 GREATER MACK AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
ST CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48080-1486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-884-7566
Provider Business Mailing Address Fax Number:
313-884-3140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24025 GREATER MACK AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ST CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48080-1486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-884-7566
Provider Business Practice Location Address Fax Number:
313-884-3140
Provider Enumeration Date:
02/15/2006

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: 213ES0103X , with the licence number:  5901002021 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4476009 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com