Provider Demographics
NPI:1134373483
Name:DIMITRI DERMATOLOGY
Entity type:Organization
Organization Name:DIMITRI DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIMITRI
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:504-391-7540
Mailing Address - Street 1:300 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5540
Mailing Address - Country:US
Mailing Address - Phone:985-643-4512
Mailing Address - Fax:985-643-4513
Practice Address - Street 1:300 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5540
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:2008-11-13
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14885R207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty