Provider Demographics
NPI:1033197405
Name:DIMIDJIAN, CARLOS A (DPM)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:DIMIDJIAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 W FM 700
Mailing Address - Street 2:STE B
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720
Mailing Address - Country:US
Mailing Address - Phone:432-267-1441
Mailing Address - Fax:432-267-1442
Practice Address - Street 1:1608 W FM 700
Practice Address - Street 2:STE B
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720
Practice Address - Country:US
Practice Address - Phone:432-267-1441
Practice Address - Fax:432-267-1442
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0935213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110214703Medicaid
TXL98NMedicare ID - Type Unspecified
T13017Medicare UPIN