Provider Demographics
NPI:1659473825
Name:KUZNETSOV, DIMITRI D (MD)
Entity Type:Individual
Prefix:MR
First Name:DIMITRI
Middle Name:D
Last Name:KUZNETSOV
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:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368
Mailing Address - Country:US
Mailing Address - Phone:360-385-5852
Mailing Address - Fax:
Practice Address - Street 1:1274 7TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368
Practice Address - Country:US
Practice Address - Phone:360-385-2905
Practice Address - Fax:360-385-6796
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042014208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H72278Medicare UPIN
WAG885111Medicare PIN