Provider Demographics
NPI:1609860733
Name:PRIMAK, DMITRY E (MD)
Entity Type:Individual
Prefix:
First Name:DMITRY
Middle Name:E
Last Name:PRIMAK
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 1:3012 QUEBRADA CIR
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-8337
Mailing Address - Country:US
Mailing Address - Phone:551-580-5179
Mailing Address - Fax:760-867-2135
Practice Address - Street 1:3012 QUEBRADA CIR
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-8337
Practice Address - Country:US
Practice Address - Phone:551-580-5179
Practice Address - Fax:760-867-2135
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0647442084P0800X
CAC1436112084P0800X
CAC1426112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ500963Medicare ID - Type Unspecified
NJG40582Medicare UPIN