Provider Demographics
NPI:1578678595
Name:IKONOMIDIS, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:IKONOMIDIS
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 1:221 W. COLORADO BLVD.
Mailing Address - Street 2:PAVILION II SUITE 728
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208
Mailing Address - Country:US
Mailing Address - Phone:469-695-2055
Mailing Address - Fax:469-695-2056
Practice Address - Street 1:221 W. COLORADO BLVD.
Practice Address - Street 2:PAVILION II SUITE 728
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208
Practice Address - Country:US
Practice Address - Phone:469-695-2055
Practice Address - Fax:469-695-2056
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXW0185208G00000X
SC22034208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT61304Medicaid
SCT61304Medicaid