Provider Demographics
NPI:1194988915
Name:PAGOULATO, DIMITRI NICHOLAS (PAC)
Entity type:Individual
Prefix:
First Name:DIMITRI
Middle Name:NICHOLAS
Last Name:PAGOULATO
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-774-7320
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:6516 E MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-4348
Practice Address - Country:US
Practice Address - Phone:225-774-7320
Practice Address - Fax:225-774-5432
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200193363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1189871Medicaid
LA1189871Medicaid
LA5CQ60PA10Medicare PIN