Healthcare Provider Details

I. General information

NPI: 1114488947
Provider Name (Legal Business Name): DMITRIY GAGARKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 BROADWAY FL 23
NEW YORK NY
10006-1452
US

IV. Provider business mailing address

165 BROADWAY FL 23
NEW YORK NY
10006-1452
US

V. Phone/Fax

Practice location:
  • Phone: 332-373-1411
  • Fax: 332-373-1415
Mailing address:
  • Phone: 332-373-1411
  • Fax: 332-373-1415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number316918
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: