Healthcare Provider Details

I. General information

NPI: 1023929783
Provider Name (Legal Business Name): DIMITRY POLISHCHUK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MC NISH WAY
CALDWELL NJ
07006-3801
US

IV. Provider business mailing address

40 MC NISH WAY
CALDWELL NJ
07006-3801
US

V. Phone/Fax

Practice location:
  • Phone: 917-579-6742
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2101733261
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: