Provider Demographics
NPI:1821285974
Name:E. M. DIMITRI, D.O. PMC
Entity Type:Organization
Organization Name:E. M. DIMITRI, D.O. PMC
Other - Org Name:DIMITRI DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-229-7451
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 1:2104 GAUSE BLVD W
Practice Address - Street 2:SUITE A
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-4130
Practice Address - Country:US
Practice Address - Phone:985-643-4575
Practice Address - Fax:985-643-4513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14885R207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07454201Medicaid
LA2109511Medicaid
LA2109511Medicaid
MS302G709564Medicare PIN