Provider Demographics
NPI:1003834995
Name:DIMITRIEVICH, ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:DIMITRIEVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W 18TH ST
Mailing Address - Street 2:OBGYN SPECIALTY CLINIC
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105
Mailing Address - Country:US
Mailing Address - Phone:605-338-0836
Mailing Address - Fax:605-338-7890
Practice Address - Street 1:625 W 18TH ST
Practice Address - Street 2:OBGYN SPECIALTY CLINIC
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-338-0836
Practice Address - Fax:605-338-7890
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT3072207VX0000X
SD3478207V00000X
MO2018041689207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6200662Medicaid
SDS40492Medicare PIN
SD6200662Medicaid