Provider Demographics
NPI:1962710699
Name:CHAMOGEORGAKIS, THEMISTOKLES
Entity type:Individual
Prefix:
First Name:THEMISTOKLES
Middle Name:
Last Name:CHAMOGEORGAKIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 JUNIUS ST STE 415
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1630
Mailing Address - Country:US
Mailing Address - Phone:214-820-7100
Mailing Address - Fax:
Practice Address - Street 1:3900 JUNIUS ST STE 415
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1615
Practice Address - Country:US
Practice Address - Phone:214-820-7100
Practice Address - Fax:214-820-6863
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3698208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3057283-02Medicaid
TX3057283-01Medicaid
TX298678YKTPMedicare PIN
TX3057283-02Medicaid
TXTXB162803Medicare PIN