Healthcare Provider Details

I. General information

NPI: 1285598672
Provider Name (Legal Business Name): DIMITRI GUSEV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WASHINGTON LN # W224
JENKINTOWN PA
19046-3505
US

IV. Provider business mailing address

101 WASHINGTON LN # W224
JENKINTOWN PA
19046-3505
US

V. Phone/Fax

Practice location:
  • Phone: 215-403-6984
  • Fax: 215-403-6984
Mailing address:
  • Phone: 215-403-6984
  • Fax: 215-403-6984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN315015
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: