=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942375654
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DMITRY D GORELIK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 01/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 197 WYCKOFF AVE
-----------------------------------------------------
City | WYCKOFF
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07481-2548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-331-9154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 197 WYCKOFF AVE
-----------------------------------------------------
City | WYCKOFF
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07481-2548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 2383000-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 25MA09799700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------