Provider Demographics
NPI:1598801573
Name:ILYEVSKY, DMITRY (MD)
Entity Type:Individual
Prefix:
First Name:DMITRY
Middle Name:
Last Name:ILYEVSKY
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 1:369 93RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-6901
Mailing Address - Country:US
Mailing Address - Phone:718-680-6000
Mailing Address - Fax:718-680-3682
Practice Address - Street 1:369 93RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-6901
Practice Address - Country:US
Practice Address - Phone:718-680-6000
Practice Address - Fax:718-680-3682
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260048207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03375275Medicaid
NYA400055749Medicare PIN