MEDICARE: MR. DIMITRI A YANEZ MD FAC OG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	13297	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568537025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DIMITRI A YANEZ MD FAC OG

Provider Business Mailing Address
First Line	:	PO BOX 2778
Second Line	:
City	:	BAY SAINT LOUIS
State	:	MS
Zip	:	39520
Country	:	US
Telephone Number	:	228-467-2555
Fax Number	:	228-467-5480

Provider Business Practice Location Address
First Line	:	1009 BENIGNO LANE
Second Line	:
City	:	BAY SAINT LOUIS
State	:	MS
Zip	:	39520
Country	:	US
Telephone Number	:	228-467-2555
Fax Number	:	228-467-5480

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	12/15/2010

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