Healthcare Provider Details

I. General information

NPI: 1588644272
Provider Name (Legal Business Name): DMITRI PETRYCHENKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 OCEAN AVE FL 6
BROOKLYN NY
11235-3202
US

IV. Provider business mailing address

2960 OCEAN AVE FL 6
BROOKLYN NY
11235-3202
US

V. Phone/Fax

Practice location:
  • Phone: 718-336-5123
  • Fax: 718-336-5137
Mailing address:
  • Phone: 718-336-5123
  • Fax: 718-336-5137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number227434
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number25MA07665400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME107824
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number227434
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: