Provider Demographics
NPI:1295015089
Name:MARKIV, DMITRIY
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:MARKIV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:AMD
Other - Middle Name:
Other - Last Name:MEDICAL SUPPLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OWNER
Mailing Address - Street 1:3108 ARDEN WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2002
Mailing Address - Country:US
Mailing Address - Phone:916-485-2500
Mailing Address - Fax:916-485-2500
Practice Address - Street 1:3108 ARDEN WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2002
Practice Address - Country:US
Practice Address - Phone:916-485-2500
Practice Address - Fax:916-485-2500
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA348977332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA54748OtherSTATE OF CALIFORNIA HOME MEDICAL DEVICE RETAIL LICENSE
CA348977OtherCOUNTY OF SACRAMENTO GENERAL BUSINESS LICENSE
CA348977OtherCOUNTY OF SACRAMENTO GENERAL BUSINESS LICENSE