Healthcare Provider Details

I. General information

NPI: 1083145171
Provider Name (Legal Business Name): DAVID JAMES DIMITROFF JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 CALUMET AVE STE B
VALPARAISO IN
46383-3328
US

IV. Provider business mailing address

1610 CALUMET AVE STE B
VALPARAISO IN
46383-3328
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-4655
  • Fax: 219-462-2491
Mailing address:
  • Phone: 219-462-4655
  • Fax: 219-462-2491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01083263A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: