Basic Information
| Provider Information | |||||||||
| NPI: | 1124373030 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAPIRO DIMITRI MEDICAL, LLC | ||||||||
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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: | 1312 22ND AVE | ||||||||
| Address2: | SUITE #A | ||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017012220 | ||||||||
| FaxNumber: | 6014839520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 12/17/2015 | ||||||||
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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 | 207N00000X | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.