Provider Demographics
NPI:1861717860
Name:MOUTSIAKIS, DEMETRIUS (MD, MPH)
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:MOUTSIAKIS
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HORSEBLOCK RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1252
Mailing Address - Country:US
Mailing Address - Phone:631-698-1552
Mailing Address - Fax:
Practice Address - Street 1:400 HORSEBLOCK RD
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1252
Practice Address - Country:US
Practice Address - Phone:631-698-1552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212315-12083P0901X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine