Provider Demographics
NPI:1720222649
Name:MALYSHEV, DMITRIY (OTA)
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:MALYSHEV
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 102ND ST APT 5C
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4528
Mailing Address - Country:US
Mailing Address - Phone:718-909-2375
Mailing Address - Fax:
Practice Address - Street 1:6612 102ND ST APT 5C
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4528
Practice Address - Country:US
Practice Address - Phone:718-909-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007206224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant