Provider Demographics
NPI:1598768038
Name:DMYTRIW, KEVIN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RICHARD
Last Name:DMYTRIW
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 1:524 SOUTHPARK BOULEVARD
Mailing Address - Street 2:JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834
Mailing Address - Country:US
Mailing Address - Phone:804-504-7980
Mailing Address - Fax:804-504-7991
Practice Address - Street 1:524 SOUTHPARK BOULEVARD
Practice Address - Street 2:JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834
Practice Address - Country:US
Practice Address - Phone:804-504-7980
Practice Address - Fax:804-504-7991
Is Sole Proprietor?:No
Enumeration Date:2005-05-28
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ33539207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine