Provider Demographics
NPI:1871798538
Name:DIAMANTIDIS, CLARISSA JONAS (MD)
Entity type:Individual
Prefix:DR
First Name:CLARISSA
Middle Name:JONAS
Last Name:DIAMANTIDIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CLARISSA
Other - Middle Name:MARIA
Other - Last Name:JONAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-713-4156
Mailing Address - Fax:336-716-7359
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1544
Practice Address - Country:US
Practice Address - Phone:336-713-4156
Practice Address - Fax:336-716-4359
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD70807207RN0300X
NC2014-01223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD510360600Medicaid
MD965568-01 & 02OtherCAREFIRST BC/BS
MDS062-0394OtherCAREFIRST BC/BS REGIONAL
MDS062-0394OtherCAREFIRST BC/BS REGIONAL