Healthcare Provider Details

I. General information

NPI: 1083059190
Provider Name (Legal Business Name): DIMITRI ORGERON MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 N MCKENZIE ST SUITE 106
FOLEY AL
36535-2261
US

IV. Provider business mailing address

2104 GAUSE BLVD W SUITE A
SLIDELL LA
70460-4130
US

V. Phone/Fax

Practice location:
  • Phone: 985-643-4512
  • Fax: 985-643-4513
Mailing address:
  • Phone: 985-643-4512
  • Fax: 985-643-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number32590
License Number StateAL

VIII. Authorized Official

Name: ELIZABETH M. DIMITRI
Title or Position: PHYSICIAN/OWNER
Credential: D.O.
Phone: 985-643-4512