Healthcare Provider Details

I. General information

NPI: 1861703399
Provider Name (Legal Business Name): IRENE DMITRUK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9660 WICKER AVE
SAINT JOHN IN
46373-9487
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-365-1177
  • Fax: 219-703-6662
Mailing address:
  • Phone: 201-961-2477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number11014502A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02003817A
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: