Healthcare Provider Details

I. General information

NPI: 1285700732
Provider Name (Legal Business Name): ELIZABETH M DIMITRI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GAUSE BLVD W STE. A
SLIDELL LA
70460-4130
US

IV. Provider business mailing address

2104 GAUSE BLVD W STE. A
SLIDELL LA
70460-4130
US

V. Phone/Fax

Practice location:
  • Phone: 985-643-4575
  • Fax: 985-643-4513
Mailing address:
  • Phone: 985-643-4575
  • Fax: 985-643-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number14885R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: