MEDICARE: DMITRY SHESTAKOVSKY DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	020632-1	NY

General Provider Information

NPI Number	:	1467502922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DMITRY SHESTAKOVSKY DPT

Provider Business Mailing Address
First Line	:	444 NEPTUNE AVE APT 10M
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224-4421
Country	:	US
Telephone Number	:	718-996-9493
Fax Number	:

Provider Business Practice Location Address
First Line	:	2327 83RD ST STE C
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-2749
Country	:	US
Telephone Number	:	718-996-9929
Fax Number	:	718-265-1807

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	12/14/2011

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