Healthcare Provider Details

I. General information

NPI: 1093959066
Provider Name (Legal Business Name): DMITRY GELLER OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1847 81ST ST
BROOKLYN NY
11214-2204
US

IV. Provider business mailing address

1847 81ST ST
BROOKLYN NY
11214-2204
US

V. Phone/Fax

Practice location:
  • Phone: 347-432-9057
  • Fax:
Mailing address:
  • Phone: 347-432-9057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number007879
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: