Provider Demographics
NPI:1609823111
Name:DIMRI, MANISH (MD)
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:
Last Name:DIMRI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 N MIDLAND DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-6407
Mailing Address - Country:US
Mailing Address - Phone:432-699-5111
Mailing Address - Fax:432-699-0773
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-335-1777
Practice Address - Fax:432-335-1815
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5134207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4067199OtherBLUE SHIELD OF TENNESSEE
TN3864119Medicaid
TN4067199OtherBLUE SHIELD OF TENNESSEE
TNH45487Medicare UPIN