Provider Demographics
NPI:1629241336
Name:AKSELROD, DMITRIY GRIGORIY (MD)
Entity Type:Individual
Prefix:DR
First Name:DMITRIY
Middle Name:GRIGORIY
Last Name:AKSELROD
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 1:111 COLCHESTER AVE
Mailing Address - Street 2:UVM MEDICAL CENTER, DEPT OF RADIOLOGY
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1473
Mailing Address - Country:US
Mailing Address - Phone:802-847-2030
Mailing Address - Fax:802-847-8493
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:UVM MEDICAL CENTER, DEPT OF RADIOLOGY
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2030
Practice Address - Fax:802-847-8493
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD603466552085R0202X
IDM-122812085R0202X
VT042.00120732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA322483OtherLNI PROVIDER ID
WA322484OtherLNI PROVIDER ID
WA318285OtherLNI PROVIDER ID
ID1629241336Medicaid
WA318285OtherLNI PROVIDER ID
WAP01277137Medicare PIN
WAG8924706Medicare PIN
WAG8924712Medicare PIN
WAP01277150Medicare PIN
WA322484OtherLNI PROVIDER ID
WA322483OtherLNI PROVIDER ID
WAG8924795Medicare PIN
WAP012277146Medicare PIN
ID20004757Medicare PIN