MEDICARE: DR. DIMITRY A. FOMIN 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	2084N0400X	Neurology Physician	E5557	AR
2	207RS0012X	Sleep Medicine (Internal Medicine) Physician	E5557	AR

General Provider Information

NPI Number	:	1831171263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIMITRY A. FOMIN MD

Provider Business Mailing Address
First Line	:	2708 RIFE MEDICAL LN
Second Line	:	SUITE 200
City	:	ROGERS
State	:	AR
Zip	:	72758-1452
Country	:	US
Telephone Number	:	479-338-3720
Fax Number	:	479-338-3749

Provider Business Practice Location Address
First Line	:	2708 RIFE MEDICAL LN
Second Line	:	SUITE 200
City	:	ROGERS
State	:	AR
Zip	:	72758-1452
Country	:	US
Telephone Number	:	479-338-3720
Fax Number	:	479-338-3749

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

Provider Enumeration Date	:	11/21/2005
Last Update Date	:	10/31/2013

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