MEDICARE: DIMITRY SAMUEL DAVYDOW M.D.

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	2084P0015X	Psychosomatic Medicine Physician	ME165986	FL
2	2084P0800X	Psychiatry Physician	ME165986	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0257115	OTHER	WA	L&I
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619911930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIMITRY SAMUEL DAVYDOW M.D.

Provider Business Mailing Address
First Line	:	PO BOX 100183
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32610-0183
Country	:	US
Telephone Number	:	352-265-4357
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 SW ARCHER RD
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32610-0001
Country	:	US
Telephone Number	:	352-265-0301
Fax Number	:

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	12/29/2023

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