Healthcare Provider Details

I. General information

NPI: 1851977292
Provider Name (Legal Business Name): DIMITRI DE KOUCHKOVSKY MD-PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 01/01/2026
Certification Date: 01/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3613 VISTA WAY
OCEANSIDE CA
92056-4522
US

IV. Provider business mailing address

3613 VISTA WAY
OCEANSIDE CA
92056-4522
US

V. Phone/Fax

Practice location:
  • Phone: 760-758-5340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA181607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: