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General NPI Number Information
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NPI Number | 1679736953
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Entity Type | Individual
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Provider Name | DMITRY LISENENKOV M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/07/2008
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Last Update Date | 05/02/2024
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Provider Practice Location Address
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Address Line | 475 SEAVIEW AVE CARDIOTHORACIC ICU
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City | STATEN ISLAND
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State | NY
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Zip | 10305
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Country | US
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Telephone | 718-775-7770
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Fax |
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Provider Business Mailing Address
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Address Line | 475 SEAVIEW AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10305-3436
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Country | US
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Telephone | 718-775-7770
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Fax |
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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 | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | 249407
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 207LC0200X
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Taxonomy Name | Critical Care Medicine (Anesthesiology) Physician
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License Number | 25MA11111600
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License Number State | NJ
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