MEDICARE: DIMITRI MICHAEL TSALICKIS DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207R00000X	Internal Medicine Physician	OS17144	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700373669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIMITRI MICHAEL TSALICKIS DO

Provider Business Mailing Address
First Line	:	11178 STATE ROAD 54 STE A
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34655-2266
Country	:	US
Telephone Number	:	727-372-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	11178 STATE ROAD 54 STE A
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34655-2266
Country	:	US
Telephone Number	:	727-372-4200
Fax Number	:	727-333-6371

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	08/24/2022

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