Provider Demographics
NPI:1205843349
Name:DK TOTAL MEDICAL PC
Entity Type:Organization
Organization Name:DK TOTAL MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YUTSIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-275-7860
Mailing Address - Street 1:9530 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1136
Mailing Address - Country:US
Mailing Address - Phone:718-275-7860
Mailing Address - Fax:718-275-7882
Practice Address - Street 1:9530 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1136
Practice Address - Country:US
Practice Address - Phone:718-275-7860
Practice Address - Fax:718-275-7882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02368849Medicaid