Provider Demographics
NPI:1689803736
Name:KHODORSKIY, DMITRIY O (MD)
Entity Type:Individual
Prefix:DR
First Name:DMITRIY
Middle Name:O
Last Name:KHODORSKIY
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 1:222 STATION PLZ N STE 429
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3889
Mailing Address - Country:US
Mailing Address - Phone:516-663-4623
Mailing Address - Fax:516-663-8500
Practice Address - Street 1:222 STATION PLZ N STE 429
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3889
Practice Address - Country:US
Practice Address - Phone:516-663-4623
Practice Address - Fax:516-663-8500
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA132741207R00000X, 207RG0100X
NY265957207R00000X, 207RG0100X
CT054753207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03530641Medicaid