Basic Information
| Provider Information | |||||||||
| NPI: | 1386850691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGIOMAVRITIS | ||||||||
| FirstName: | DEMOSTHENES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 367 PLANTATION ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083341443 | ||||||||
| FaxNumber: | 5083341448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 47165 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2078767 | 05 | MA | MEDICAID | 701827 | 01 | MA | TUFTS | OTHER | N01922 | 01 | MA | BLUE CROSS | OTHER | 202787175 | 01 | MA | CHAMPUS | OTHER | 202787175 | 01 | MA | UNITED HEALTHCARE | OTHER | 9751530 | 05 | MA | MEDICAID | M18983 | 01 | MA | BLUE CROSS | OTHER | 202787175 | 01 | MA | CIGNA | OTHER | 202787175 | 01 | MA | GREAT WEST | OTHER | 202787175 | 01 | MA | AETNA | OTHER | 26373 | 01 | MA | FALLON | OTHER | 999969 | 01 | MA | NETWORK HEALTH | OTHER | 202787175 | 01 | MA | TAX ID | OTHER | 202787175 | 01 | MA | NETWORK HEALTH | OTHER | 61250 | 01 | MA | HARVARD PILGRIM | OTHER |