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NPI Code Detail

MEDICARE: DIMITRY PETTAWAY

MEDICARE: DIMITRY PETTAWAY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist

General Provider Information

NPI Number : 1154203164
Entity Type Code : Individual
Provider Name (Legal Business Name) : DIMITRY PETTAWAY
Provider Business Mailing Address
First Line : 576 BROADHOLLOW RD
Second Line :
City : MELVILLE
State : NY
Zip : 11747-5012
Country : US
Telephone Number : 631-359-5859
Fax Number :
Provider Business Practice Location Address
First Line : 2837 LONG BEACH RD
Second Line :
City : OCEANSIDE
State : NY
Zip : 11572-2233
Country : US
Telephone Number : 516-461-6919
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/22/2025
Last Update Date : 07/22/2025

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Directions to “ DIMITRY PETTAWAY ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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