Provider Demographics
NPI:1285645531
Name:TCKACHENKO, DMITRIY SERGEEVICK (MD)
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:SERGEEVICK
Last Name:TCKACHENKO
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-577-4200
Practice Address - Fax:317-577-9503
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35378207L00000X
IN01089003A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN095200131OtherMEDICARE PTAN
P00353901OtherMEDICARE RAILROAD
AZ117490Medicaid
IN300071919Medicaid
IN364430307OtherMEDICARE