Provider Demographics
NPI:1427020759
Name:KOSYAGIN, DMITRIY (MD)
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:KOSYAGIN
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 1:4835 S DURANGO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8171
Mailing Address - Country:US
Mailing Address - Phone:702-877-5199
Mailing Address - Fax:702-984-5194
Practice Address - Street 1:4835 S DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8171
Practice Address - Country:US
Practice Address - Phone:702-877-5199
Practice Address - Fax:702-984-5194
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11097207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504139Medicaid
NVV40632Medicare PIN
NV40632Medicare PIN
NVGC128ZMedicare PIN
NV100504139Medicaid