Healthcare Provider Details

I. General information

NPI: 1225293491
Provider Name (Legal Business Name): DMITRI IGONKIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2008
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

IV. Provider business mailing address

4802 10TH AVE
BROOKLYN NY
11219-2916
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-7009
  • Fax:
Mailing address:
  • Phone: 718-283-6151
  • Fax: 718-635-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA10047100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number25MA10047100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number254633
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number254633
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number254633
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: