Provider Demographics
NPI:1730132689
Name:VASIN, DMITRI V (MD)
Entity Type:Individual
Prefix:
First Name:DMITRI
Middle Name:V
Last Name:VASIN
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 1:840 CALLAHAN DR
Mailing Address - Street 2:STE A
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310
Mailing Address - Country:US
Mailing Address - Phone:360-479-0349
Mailing Address - Fax:360-479-0065
Practice Address - Street 1:840 CALLAHAN DR
Practice Address - Street 2:STE A
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310
Practice Address - Country:US
Practice Address - Phone:360-479-0349
Practice Address - Fax:360-479-0065
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038345207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1036VAOtherREGENCE BLUE SHIELD
WA1110634Medicaid
WAG8852908Medicare ID - Type Unspecified
G40163Medicare UPIN