Provider Demographics
NPI:1053356204
Name:MISAILIDIS, DIMITRI (MD)
Entity type:Individual
Prefix:
First Name:DIMITRI
Middle Name:
Last Name:MISAILIDIS
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 1:300 FOXCROFT AVE
Mailing Address - Street 2:SUITE 202B
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-5341
Mailing Address - Country:US
Mailing Address - Phone:304-263-4967
Mailing Address - Fax:304-267-5461
Practice Address - Street 1:300 FOXCROFT AVE
Practice Address - Street 2:SUITE 202B
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-5341
Practice Address - Country:US
Practice Address - Phone:304-263-4967
Practice Address - Fax:304-267-5461
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV158752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000848955OtherWV BCBS
WV0118129000Medicaid
MD535851500Medicaid
MD535851500Medicaid
MI0646561Medicare PIN