Provider Demographics
NPI:1164081584
Name:BOREISHA, DIMITRI (DO)
Entity Type:Individual
Prefix:
First Name:DIMITRI
Middle Name:
Last Name:BOREISHA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:DMYTRO
Other - Middle Name:
Other - Last Name:BOREISHA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-2682
Mailing Address - Fax:515-643-5802
Practice Address - Street 1:1111 6TH AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2613
Practice Address - Country:US
Practice Address - Phone:515-643-2682
Practice Address - Fax:515-643-5802
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-116552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry