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General NPI Number Information
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NPI Number | 1184158602
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Entity Type | Individual
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Provider Name | SERGEI VENIAMINOVICH DMITRUK MD
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Gender | Male
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Dates
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Enumeration Date | 04/12/2017
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 4010 DUPONT CIR STE 380
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City | LOUISVILLE
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State | KY
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Zip | 40207-4881
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Country | US
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Telephone | 502-895-0040
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Fax | 502-214-3429
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Provider Business Mailing Address
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Address Line | 1935 BLUEGRASS AVE STE 200
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City | LOUISVILLE
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State | KY
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Zip | 40215-1181
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Country | US
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Telephone | 502-364-0033
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Fax | 502-361-4488
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 01085592A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 54890
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License Number State | KY
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