Provider Demographics
NPI:1457657280
Name:GONCHAROV, DIMITRY (DO)
Entity Type:Individual
Prefix:DR
First Name:DIMITRY
Middle Name:
Last Name:GONCHAROV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 MADISON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-0701
Mailing Address - Country:US
Mailing Address - Phone:212-201-1217
Mailing Address - Fax:646-843-7617
Practice Address - Street 1:274 MADISON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-0701
Practice Address - Country:US
Practice Address - Phone:212-201-1217
Practice Address - Fax:646-843-7617
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269283207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology