Provider Demographics
NPI:1285660803
Name:MANTZOROS, DIMITRIOS SPIROS (DPM)
Entity type:Individual
Prefix:
First Name:DIMITRIOS
Middle Name:SPIROS
Last Name:MANTZOROS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 RIVERWOOD CT STE 220
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2974
Mailing Address - Country:US
Mailing Address - Phone:936-756-9191
Mailing Address - Fax:936-756-9197
Practice Address - Street 1:1020 RIVERWOOD CT STE 220
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2974
Practice Address - Country:US
Practice Address - Phone:936-756-9191
Practice Address - Fax:936-756-9197
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1068213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110718701Medicaid
TX480018641Medicare PIN
TX00A77LMedicare PIN
TX110718701Medicaid