=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588644272
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DMITRI PETRYCHENKO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2006
-----------------------------------------------------
Last Update Date | 08/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2960 OCEAN AVE FL 6
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-336-5123
-----------------------------------------------------
Fax | 718-336-5137
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2960 OCEAN AVE FL 6
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-336-5123
-----------------------------------------------------
Fax | 718-336-5137
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 227434
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 25MA07665400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | ME107824
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 227434
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------