Healthcare Provider Details

I. General information

NPI: 1740817774
Provider Name (Legal Business Name): DMITRIY PERESADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W 59TH ST FL 6
NEW YORK NY
10019-8022
US

IV. Provider business mailing address

425 W 59TH ST FL 6
NEW YORK NY
10019-8022
US

V. Phone/Fax

Practice location:
  • Phone: 212-523-8159
  • Fax:
Mailing address:
  • Phone: 312-217-5806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: