Healthcare Provider Details

I. General information

NPI: 1114109089
Provider Name (Legal Business Name): DMITRI ANDREYEVICH GAGARIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16000 JOHNSTON MEMORIAL DR FL 4
ABINGDON VA
24211-7664
US

IV. Provider business mailing address

7734 ASTERELLA CT
SPRINGFIELD VA
22152-3141
US

V. Phone/Fax

Practice location:
  • Phone: 276-258-1000
  • Fax:
Mailing address:
  • Phone: 202-415-9039
  • Fax: 888-435-7279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.096436
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101250254
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2081H0002X
TaxonomyHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
License NumberD0082658
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101250254
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: