Provider Demographics
NPI:1689801581
Name:ROYTMAN, DMITRY (LO)
Entity Type:Individual
Prefix:MR
First Name:DMITRY
Middle Name:
Last Name:ROYTMAN
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4751
Mailing Address - Country:US
Mailing Address - Phone:203-926-1189
Mailing Address - Fax:203-925-0855
Practice Address - Street 1:465 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4751
Practice Address - Country:US
Practice Address - Phone:203-926-1189
Practice Address - Fax:203-925-0855
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001395156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician