Provider Demographics
NPI:1568537025
Name:YANEZ, DIMITRI A (MD FAC OG)
Entity Type:Individual
Prefix:MR
First Name:DIMITRI
Middle Name:A
Last Name:YANEZ
Suffix:
Gender:M
Credentials:MD FAC OG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2778
Mailing Address - Street 2:
Mailing Address - City:BAY SAINT LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520
Mailing Address - Country:US
Mailing Address - Phone:228-467-2555
Mailing Address - Fax:228-467-5480
Practice Address - Street 1:1009 BENIGNO LANE
Practice Address - Street 2:
Practice Address - City:BAY SAINT LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520
Practice Address - Country:US
Practice Address - Phone:228-467-2555
Practice Address - Fax:228-467-5480
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13297207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015700OtherMEDICAID GROUP
MS00124369Medicaid
MS160000260Medicare ID - Type Unspecified
MS00124369Medicaid