Healthcare Provider Details

I. General information

NPI: 1609860733
Provider Name (Legal Business Name): DMITRY E PRIMAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2005
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 SANTA FE DR STE 200
ENCINITAS CA
92024-5137
US

IV. Provider business mailing address

351 SANTA FE DR STE 200
ENCINITAS CA
92024-5137
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA064744
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC142611
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: