Provider Demographics
NPI:1144575960
Name:EDEM, DINESH LAXMINARA
Entity type:Individual
Prefix:
First Name:DINESH LAXMINARA
Middle Name:
Last Name:EDEM
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 1:10001 LILE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6217
Mailing Address - Country:US
Mailing Address - Phone:501-552-0500
Mailing Address - Fax:501-552-5318
Practice Address - Street 1:10001 LILE DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6217
Practice Address - Country:US
Practice Address - Phone:501-552-0500
Practice Address - Fax:501-552-5318
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-14762207R00000X, 207RE0101X
IN01078017A207R00000X
MDP27586207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001094186OtherANTHEM