Healthcare Provider Details

I. General information

NPI: 1336314889
Provider Name (Legal Business Name): DIMITRIOS JOHN FOTIADIS MD PYSICIAN SURGEON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 GROVE STR
CLIFTON NJ
07013
US

IV. Provider business mailing address

337 GROVE STR
CLIFTON NJ
07013
US

V. Phone/Fax

Practice location:
  • Phone: 973-779-3787
  • Fax: 973-778-6433
Mailing address:
  • Phone:
  • Fax: 973-778-6433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA01891100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MA01891100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: