Healthcare Provider Details

I. General information

NPI: 1467502922
Provider Name (Legal Business Name): DMITRY SHESTAKOVSKY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2327 83RD ST STE C
BROOKLYN NY
11214-2749
US

IV. Provider business mailing address

444 NEPTUNE AVE APT 10M
BROOKLYN NY
11224-4421
US

V. Phone/Fax

Practice location:
  • Phone: 718-996-9929
  • Fax: 718-265-1807
Mailing address:
  • Phone: 718-996-9493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number020632-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: