MEDICARE: DMITRY KHASAK MD PC INC

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1679835946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DMITRY KHASAK MD PC INC

Provider Business Mailing Address
First Line	:	100 PAVONIA AVE STE 409
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07310-2778
Country	:	US
Telephone Number	:	201-626-4040
Fax Number	:	866-861-0767

Provider Business Practice Location Address
First Line	:	100 PAVONIA AVE STE 409
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07310-2778
Country	:	US
Telephone Number	:	201-626-4040
Fax Number	:	866-861-0767

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. EUGENE GERLANTS
Credential	:
Telephone Number	:	201-889-7047

Provider Enumeration Date	:	06/13/2012
Last Update Date	:	06/13/2012

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