Provider Demographics
NPI:1710025614
Name:LENIKMAN, DIMITRY
Entity Type:Individual
Prefix:MR
First Name:DIMITRY
Middle Name:
Last Name:LENIKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 W LIEBAU RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2620
Mailing Address - Country:US
Mailing Address - Phone:414-364-5056
Mailing Address - Fax:262-243-9987
Practice Address - Street 1:1575 W LIEBAU RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-2620
Practice Address - Country:US
Practice Address - Phone:414-364-5056
Practice Address - Fax:262-243-9987
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41474700Medicaid