Healthcare Provider Details

I. General information

NPI: 1609843937
Provider Name (Legal Business Name): JAMES GUS DEMITRACK JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2006
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NBHC IWAKUNI, BLDG 110, MCAS IWAKUNI 1 MISUMI MACHI
IWAKUNI YAMAGUCHI
7400025
JP

IV. Provider business mailing address

PSC 561 BOX 1877
FPO AP
96310-0019
US

V. Phone/Fax

Practice location:
  • Phone: 315-255-8298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101238544
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: