Provider Demographics
NPI:1275534323
Name:DIMITRY, EDWARD A (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:DIMITRY
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 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 SPRINGFIELD AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-4055
Practice Address - Country:US
Practice Address - Phone:908-934-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06224300207RP1001X
PAMD042441L207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ222233003OtherHORIZON BC
NJ77U432OtherEMPIRE HEALTH
NJ222233003035OtherCIGNA
NJ5043040OtherAETNA
NJCHNOther1216963
NJ290008483OtherRAILROAD MEDICARE
NJP400548OtherOXFORD
NJ718209AP7Medicare ID - Type UnspecifiedMEDICARE
NJ5043040OtherAETNA