Basic Information
| Provider Information | |||||||||
| NPI: | 1821285974 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | E. M. DIMITRI, D.O. PMC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DIMITRI DERMATOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 2104 GAUSE BLVD W | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704604130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856434575 | ||||||||
| FaxNumber: | 9856434513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DRAKE | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5042297451 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 14885R | LA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 2109511 | 05 | LA | MEDICAID | 07454201 | 05 | MS | MEDICAID |