Provider Demographics
NPI:1114109089
Name:GAGARIN, DMITRI ANDREYEVICH (MD)
Entity Type:Individual
Prefix:
First Name:DMITRI
Middle Name:ANDREYEVICH
Last Name:GAGARIN
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 1:7734 ASTERELLA CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-3141
Mailing Address - Country:US
Mailing Address - Phone:202-415-9039
Mailing Address - Fax:888-435-7279
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR FL 4
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00826582081H0002X
390200000X
OH35.096436207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3139008Medicaid
OHH015271Medicare PIN