Provider Demographics
NPI:1265491658
Name:DIMITRI, GEORGE RONALD (OD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:RONALD
Last Name:DIMITRI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:RONALD
Other - Middle Name:G
Other - Last Name:DIMITRI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:701 METAIRIE RD
Mailing Address - Street 2:#205
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1617 METAIRIE RD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70005-3976
Practice Address - Country:US
Practice Address - Phone:504-837-3937
Practice Address - Fax:504-837-9958
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1098-052AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1937827Medicaid
U33165Medicare UPIN
LA1937827Medicaid