Provider Demographics
NPI:1689750259
Name:DIMITROV, NADYA E (DPM)
Entity Type:Individual
Prefix:DR
First Name:NADYA
Middle Name:E
Last Name:DIMITROV
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 OLD WILLETS PATH
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4120
Mailing Address - Country:US
Mailing Address - Phone:212-420-4300
Mailing Address - Fax:631-724-3252
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:2N
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:212-420-4300
Practice Address - Fax:212-420-2310
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004243213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01100283Medicaid
NY01100283Medicaid
66PM87Medicare PIN