Healthcare Provider Details

I. General information

NPI: 1104017631
Provider Name (Legal Business Name): DMITRIY KOLKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2471 E WALNUT ST
PASADENA CA
91107-3394
US

IV. Provider business mailing address

2471 E WALNUT ST
PASADENA CA
91107-3394
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-5141
  • Fax: 626-577-4988
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: