Provider Demographics
NPI:1427506955
Name:LOUIE, DEXTER
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:LOUIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 WILLOW RD
Mailing Address - Street 2:MAIL STOP 170A/MPD
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-2539
Mailing Address - Country:US
Mailing Address - Phone:650-614-9997
Mailing Address - Fax:650-617-2687
Practice Address - Street 1:795 WILLOW RD
Practice Address - Street 2:MAIL STOP 170A/MPD
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-2539
Practice Address - Country:US
Practice Address - Phone:650-614-9997
Practice Address - Fax:650-617-2687
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT675562084P0800X
390200000X
CAA1570922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008068669Medicaid
CT008068749Medicaid
CT008068631Medicaid