MEDICARE: DR. DIMITRI NOVITZKY MD

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
1	207QA0505X	Adult Medicine Physician	ME61367	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	1215972526	OTHER		MEDICARE NPI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	11642	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1215972526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIMITRI NOVITZKY MD

Provider Business Mailing Address
First Line	:	4407 VIEUX CARRE CIR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-3052
Country	:	US
Telephone Number	:	813-390-5344
Fax Number	:	386-774-1264

Provider Business Practice Location Address
First Line	:	1001 N MACDILL AVE STE B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607
Country	:	US
Telephone Number	:	813-675-4849
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	05/27/2019

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