Provider Demographics
NPI:1124118500
Name:KLONIS, DEMOSTHENIS (DO)
Entity type:Individual
Prefix:DR
First Name:DEMOSTHENIS
Middle Name:
Last Name:KLONIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22130
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-2130
Mailing Address - Country:US
Mailing Address - Phone:575-647-8366
Mailing Address - Fax:
Practice Address - Street 1:465 SAINT MICHAELS DR
Practice Address - Street 2:SUITE 117
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7670
Practice Address - Country:US
Practice Address - Phone:505-992-2600
Practice Address - Fax:505-992-2616
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1319-05207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29203708Medicaid
NM348522101Medicare ID - Type Unspecified
NM29203708Medicaid