Provider Demographics
NPI:1255519229
Name:CARLOS A DIMIDJIAN
Entity type:Organization
Organization Name:CARLOS A DIMIDJIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIMIDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:432-267-1441
Mailing Address - Street 1:1608 W FM 700
Mailing Address - Street 2:STE B
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-4113
Mailing Address - Country:US
Mailing Address - Phone:432-267-1441
Mailing Address - Fax:432-267-1442
Practice Address - Street 1:1608 W FM 700
Practice Address - Street 2:STE B
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-4113
Practice Address - Country:US
Practice Address - Phone:432-267-1441
Practice Address - Fax:432-267-1442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX0935213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110214703Medicaid
1041590001Medicare NSC
L98NMedicare PIN
1255519229Medicare NSC
T13017Medicare UPIN