Healthcare Provider Details

I. General information

NPI: 1447451265
Provider Name (Legal Business Name): DEMETRIOS J DOUROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 W WATERTOWN PLANK RD SPORTS MEDICINE
MILWAUKEE WI
53226-3595
US

IV. Provider business mailing address

8700 W WATERTOWN PLANK RD SPORTS MEDICINE
MILWAUKEE WI
53226-3595
US

V. Phone/Fax

Practice location:
  • Phone: 414-890-5710
  • Fax: 414-805-7171
Mailing address:
  • Phone: 414-890-5710
  • Fax: 414-805-7171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number52739
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: