Healthcare Provider Details

I. General information

NPI: 1003834995
Provider Name (Legal Business Name): ELIZABETH DIMITRIEVICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W 18TH ST OBGYN SPECIALTY CLINIC
SIOUX FALLS SD
57105
US

IV. Provider business mailing address

625 W 18TH ST OBGYN SPECIALTY CLINIC
SIOUX FALLS SD
57105
US

V. Phone/Fax

Practice location:
  • Phone: 605-338-0836
  • Fax: 605-338-7890
Mailing address:
  • Phone: 605-338-0836
  • Fax: 605-338-7890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberT3072
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3478
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number2018041689
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: