Healthcare Provider Details

I. General information

NPI: 1477646800
Provider Name (Legal Business Name): DEMETRI ANTONIOU M.D.,D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SEWALL ST
PORTLAND ME
04102-2641
US

IV. Provider business mailing address

15 SEWALL ST
PORTLAND ME
04102-2641
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-1775
  • Fax: 207-774-3126
Mailing address:
  • Phone: 207-774-1775
  • Fax: 207-774-3126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number012240
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: