Healthcare Provider Details

I. General information

NPI: 1386603009
Provider Name (Legal Business Name): ROBERT W DEMETRIUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 MORNINGSIDE DR
MOUNT DORA FL
32757-6610
US

IV. Provider business mailing address

2850 MORNINGSIDE DR
MOUNT DORA FL
32757-6610
US

V. Phone/Fax

Practice location:
  • Phone: 352-383-0733
  • Fax: 352-383-7114
Mailing address:
  • Phone: 352-383-0733
  • Fax: 352-383-7114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME 68919
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME 68919
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: