Healthcare Provider Details

I. General information

NPI: 1356595862
Provider Name (Legal Business Name): DMITRY V SAMSONOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BRADHURST AVE STE 1400
HAWTHORNE NY
10532-2140
US

IV. Provider business mailing address

PO BOX 1020
HAWTHORNE NY
10532-7507
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-7583
  • Fax: 914-594-4011
Mailing address:
  • Phone: 914-493-7583
  • Fax: 914-594-4011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number003556
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number269800
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: