Provider Demographics
NPI:1861585408
Name:BOUSOUNIS, DIMITRIOS P (MD)
Entity type:Individual
Prefix:DR
First Name:DIMITRIOS
Middle Name:P
Last Name:BOUSOUNIS
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 1:200 W. SILVER SPRING DRIVE
Mailing Address - Street 2:# 255
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-964-8450
Mailing Address - Fax:414-964-8451
Practice Address - Street 1:200 W. SILVER SPRING DRIVE
Practice Address - Street 2:# 255
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-964-8450
Practice Address - Fax:414-964-8451
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27172208000000X, 2084N0402X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30679100Medicaid
WI000002344Medicare PIN
WI30679100Medicaid