Healthcare Provider Details

I. General information

NPI: 1679102750
Provider Name (Legal Business Name): ANTONIOS DIMITRI DIMOPOULOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 EVES DR STE 170
MARLTON NJ
08053-3130
US

IV. Provider business mailing address

200 SCHULZ DR STE 2
RED BANK NJ
07701-6745
US

V. Phone/Fax

Practice location:
  • Phone: 732-426-3420
  • Fax: 732-242-7681
Mailing address:
  • Phone: 732-741-0970
  • Fax: 848-800-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number25IA13080100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35.149819
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: