Provider Demographics
NPI:1386603009
Name:DEMETRIUS, ROBERT W (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:DEMETRIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6610
Mailing Address - Country:US
Mailing Address - Phone:352-383-0733
Mailing Address - Fax:352-383-7114
Practice Address - Street 1:2850 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6610
Practice Address - Country:US
Practice Address - Phone:352-383-0733
Practice Address - Fax:352-383-7114
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 68919207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32386ZMedicare PIN
F88756Medicare UPIN
FL32386YMedicare PIN