Basic Information
| Provider Information | |||||||||
| NPI: | 1487674776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIMMICK | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAHAIM | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8649 AUTUMN GREEN DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322569560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044766438 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 820 PRUDENTIAL DR STE 713 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043965682 | ||||||||
| FaxNumber: | 9043460864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME0073498 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000786871D | 05 | GA | MEDICAID | 44334 | 01 | FL | BCBS OF FLORIDA | OTHER | P00138982 | 01 | FL | RAILROAD MEDICARE | OTHER | 254874700 | 05 | FL | MEDICAID | P00395758 | 01 | RAILROAD MEDICARE | OTHER |