Provider Demographics
NPI:1588644272
Name:PETRYCHENKO, DMITRI (MD)
Entity Type:Individual
Prefix:
First Name:DMITRI
Middle Name:
Last Name:PETRYCHENKO
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 1:2960 OCEAN AVE FL 6
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3202
Mailing Address - Country:US
Mailing Address - Phone:718-336-5123
Mailing Address - Fax:718-336-5137
Practice Address - Street 1:2960 OCEAN AVE FL 6
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3202
Practice Address - Country:US
Practice Address - Phone:718-336-5123
Practice Address - Fax:718-336-5137
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227434174400000X, 208VP0014X
NJ25MA07665400208VP0014X
FLME107824208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH97199Medicare UPIN
NY9K2411Medicare ID - Type Unspecified