Provider Demographics
NPI:1033105903
Name:MYSH, DMITRY (MD)
Entity Type:Individual
Prefix:
First Name:DMITRY
Middle Name:
Last Name:MYSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6202
Mailing Address - Fax:239-437-8537
Practice Address - Street 1:16410 HEALTHPARK COMMONS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-9621
Practice Address - Country:US
Practice Address - Phone:239-343-6202
Practice Address - Fax:239-437-8537
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA065097207RG0100X
KY51971207RG0100X
FLME142694207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8503206Medicaid
FL104397900Medicaid
NJ8503206Medicaid