Provider Demographics
NPI:1023074952
Name:MANESIS, DIMITRA A (MD)
Entity type:Individual
Prefix:
First Name:DIMITRA
Middle Name:A
Last Name:MANESIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:2 ESSEX CENTER DR
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2902
Practice Address - Country:US
Practice Address - Phone:978-977-4000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52313207Q00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0120871Medicaid
MAF40459Medicare UPIN
MA0120871Medicaid