NPIMap

Individual provider Active NPI

Dimitri Nicholas Pagoulato, PAC

  • Physician Assistant
  • Baker, LA
National Provider Identifier
1194988915
Registry record updated Mar 14, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
200193 Issued in LA
Practice address
6516 E Myrtle Ave
Baker, LA 70714-4348
Phone
(225) 774-7320
Fax
(225) 774-5432
NPI assigned
Jul 2, 2008
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 14, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 200193 LA Primary

Addresses

Primary practice location

6516 E Myrtle Ave
Baker, LA 70714-4348

Mailing address

5959 S Sherwood Forest Blvd
Baton Rouge, LA 70816-6038
Phone (225) 774-7320

Other practice location 1

12525 Perkins Rd
Ste. B
Baton Rouge, LA 70810-1907
Phone (225) 819-8857

Other identifiers 1

IdentifierTypeStateIssuer
1189871MedicaidLA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20081105000004 LA Practitioner - Physician Assistant 9335215243 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2008
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

6516 E Myrtle Ave
Baker, LA 70714-4348
Phone (225) 774-7320

7777 Hennessy Blvd
Baton Rouge, LA 70808-4363

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
200193LAMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Our Lady of the Lake Physician Group, LLC CurrentSince May 5, 2025 Accepting new patients
Our Lady of the Lake Physician Group LLC CurrentSince May 5, 2025 Accepting new patients
Lake Urgent Care Ascension LLC CurrentSince Dec 29, 2020 Accepting new patients
Convenient Care LLC CurrentSince Dec 29, 2020 Accepting new patients
Convenient Care LLC CurrentSince Dec 29, 2020 Accepting new patients
Lake Urgent Care Ascension LLC CurrentSince Dec 29, 2020 Accepting new patients

Locations

6516 E Myrtle Ave
Baker, LA 70714
Phone (225) 774-7320

11424 Sullivan Rd
#A-C
Baton Rouge, LA 70818
Phone (225) 261-7021

5959 S Sherwood Forest Blvd
Baton Rouge, LA 70816
Phone (225) 526-0011

12525 Perkins Rd
#B
Baton Rouge, LA 70810
Phone (225) 819-8857

10319 Jefferson Hwy
Baton Rouge, LA 70809
Phone (224) 214-9352

5000 Hennessy Blvd
Baton Rouge, LA 70808
Phone (225) 765-4050

1776 N Airline Hwy
Ste A
Gonzales, LA 70737
Phone (225) 647-4988

14350 Highway 73
Prairieville, LA 70769
Phone (225) 313-3930

40546 Highway 42
Prairieville, LA 70769
Phone (225) 744-4988

10714 Highway 431
Saint Amant, LA 70774
Phone (225) 644-0005

Organizations & group practices 10

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1214956800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1741910400000",
    "number": "1194988915",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5959 S SHERWOOD FOREST BLVD",
            "city": "BATON ROUGE",
            "state": "LA",
            "postal_code": "708166038",
            "telephone_number": "225-774-7320",
            "fax_number": "225-765-9196"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6516 E MYRTLE AVE",
            "city": "BAKER",
            "state": "LA",
            "postal_code": "707144348",
            "telephone_number": "225-774-7320",
            "fax_number": "225-774-5432"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "12525 Perkins Rd",
            "address_2": "Ste. B",
            "address_purpose": "LOCATION",
            "city": "Baton Rouge",
            "state": "LA",
            "postal_code": "708101907",
            "country_code": "US",
            "telephone_number": "225-819-8857",
            "fax_number": "225-767-6822",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PAGOULATO",
        "first_name": "DIMITRI",
        "middle_name": "NICHOLAS",
        "credential": "PAC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-07-02",
        "last_updated": "2025-03-14",
        "certification_date": "2025-03-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "LA",
            "license": "200193",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1189871",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Baker, LA

Sources for this page

Verify at the official NPI Registry.