Provider Demographics
NPI:1649379934
Name:DASHEVSKIY, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DASHEVSKIY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3198 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1000
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:718-795-4394
Practice Address - Street 1:2015 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4303
Practice Address - Country:US
Practice Address - Phone:718-299-7295
Practice Address - Fax:718-299-6797
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02238324Medicaid
NY43V211Medicare ID - Type Unspecified
NYH56491Medicare UPIN
NY02238324Medicaid