Healthcare Provider Details

I. General information

NPI: 1124134069
Provider Name (Legal Business Name): DIMITRIS GEROTHANASSIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3442 NIXON RD
HOLIDAY FL
34691-3144
US

IV. Provider business mailing address

3442 NIXON RD
HOLIDAY FL
34691-3144
US

V. Phone/Fax

Practice location:
  • Phone: 541-622-1936
  • Fax:
Mailing address:
  • Phone: 541-622-1936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD209042
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD496988
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101289430
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC176067
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number226334
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA13241100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: