MEDICARE: DR. DMITRIY MODEL 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	207R00000X	Internal Medicine Physician	ME88320	FL

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

General Provider Information

NPI Number	:	1679521488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DMITRIY MODEL M.D.

Provider Business Mailing Address
First Line	:	1633 RACE TRACK RD
Second Line	:	SUITE 1
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259
Country	:	US
Telephone Number	:	904-230-6988
Fax Number	:	904-342-4028

Provider Business Practice Location Address
First Line	:	1633 RACE TRACK RD
Second Line	:	SUITE 1
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-4222
Country	:	US
Telephone Number	:	904-230-6988
Fax Number	:	904-342-4028

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/08/2007

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