Provider Demographics
NPI:1174595490
Name:GHECAS, DIMITRI (PA-C)
Entity type:Individual
Prefix:
First Name:DIMITRI
Middle Name:
Last Name:GHECAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 OLD PARK LANE
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776
Mailing Address - Country:US
Mailing Address - Phone:860-355-1149
Mailing Address - Fax:860-355-5957
Practice Address - Street 1:11 OLD PARK LANE
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776
Practice Address - Country:US
Practice Address - Phone:860-355-1149
Practice Address - Fax:860-355-5957
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00735363AM0700X, 363AM0700X
NY022592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00735OtherCT LICENSE
CTP2737999OtherOXFORD
CT2V3651OtherACS/HEALTHNET
CT713282OtherCONNECTICARE
CT290000735CT01OtherANTHEM BC/BS
CTP00006823OtherRAILROAD MEDICARE
CT713282OtherCONNECTICARE
CTP00006823OtherRAILROAD MEDICARE