1083059190 NPI number — DIMITRI ORGERON MEDICAL, LLC

Table of content: (NPI 1083059190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083059190 NPI number — DIMITRI ORGERON MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIMITRI ORGERON MEDICAL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083059190
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2104 GAUSE BLVD W
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
SLIDELL
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70460-4130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-643-4512
Provider Business Mailing Address Fax Number:
985-643-4513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1506 N MCKENZIE ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
FOLEY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36535-2261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-643-4512
Provider Business Practice Location Address Fax Number:
985-643-4513
Provider Enumeration Date:
05/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DIMITRI
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
985-643-4512

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  32590 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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