Provider Demographics
NPI:1083059190
Name:DIMITRI ORGERON MEDICAL, LLC
Entity Type:Organization
Organization Name:DIMITRI ORGERON MEDICAL, LLC
Other - Org Name:THE DIMITRI CLINIC - FOLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIMITRI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:985-643-4512
Mailing Address - Street 1:2104 GAUSE BLVD W
Mailing Address - Street 2:SUITE A
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-4130
Mailing Address - Country:US
Mailing Address - Phone:985-643-4512
Mailing Address - Fax:985-643-4513
Practice Address - Street 1:1506 N MCKENZIE ST
Practice Address - Street 2:SUITE 106
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2261
Practice Address - Country:US
Practice Address - Phone:985-643-4512
Practice Address - Fax:985-643-4513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-02
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL32590208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty