Organization
EM DIMITRI DO PMC
Active
Other names
Dimitri Dermatology
Organization subpart
No
Provider details
NPI number
Authorized official
KAREN RACHEL DRAKE (CREDENTIALING COORDINATOR)
(985) 643-4512
Entity
Organization
Contact information
Practice address
624 HIGHWAY 90, BAY ST LOUIS, MS 39520-2715
(228) 467-5644
(228) 467-9961
Mailing address
300 GATEWAY DR, SLIDELL, LA 70461-5540
(985) 643-4512
(985) 643-4513
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
14885R
LA
207N00000X
Dermatology Physician
21866
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07454201
—
MS
Enumeration date
05/10/2012
Last updated
05/10/2012
Update your record
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