Healthcare Provider Details

I. General information

NPI: 1710025614
Provider Name (Legal Business Name): MR. DIMITRY LENIKMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 W LIEBAU RD
MEQUON WI
53092-2620
US

IV. Provider business mailing address

1575 W LIEBAU RD
MEQUON WI
53092-2620
US

V. Phone/Fax

Practice location:
  • Phone: 414-364-5056
  • Fax: 262-243-9987
Mailing address:
  • Phone: 414-364-5056
  • Fax: 262-243-9987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: