Basic Information
| Provider Information | |||||||||
| NPI: | 1083059190 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIMITRI ORGERON MEDICAL, LLC | ||||||||
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| OtherOrganizationName: | THE DIMITRI CLINIC - FOLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2104 GAUSE BLVD W | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704604130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856434512 | ||||||||
| FaxNumber: | 9856434513 | ||||||||
| Practice Location | |||||||||
| Address1: | 1506 N MCKENZIE ST | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | FOLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365352261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856434512 | ||||||||
| FaxNumber: | 9856434513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2013 | ||||||||
| LastUpdateDate: | 11/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | DIMITRI | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9856434512 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 32590 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.