Healthcare Provider Details

I. General information

NPI: 1124118500
Provider Name (Legal Business Name): DEMOSTHENIS KLONIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 SAINT MICHAELS DR SUITE 117
SANTA FE NM
87505-7670
US

IV. Provider business mailing address

PO BOX 22130
SANTA FE NM
87502-2130
US

V. Phone/Fax

Practice location:
  • Phone: 505-992-2600
  • Fax: 505-992-2616
Mailing address:
  • Phone: 575-647-8366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA-1319-05
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: