Healthcare Provider Details

I. General information

NPI: 1609823111
Provider Name (Legal Business Name): MANISH DIMRI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W 5TH ST
ODESSA TX
79763-4206
US

IV. Provider business mailing address

1816 N MIDLAND DR
MIDLAND TX
79707-6407
US

V. Phone/Fax

Practice location:
  • Phone: 432-335-1777
  • Fax: 432-335-1815
Mailing address:
  • Phone: 432-699-5111
  • Fax: 432-699-0773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM5134
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: