Provider Demographics
NPI:1750456133
Name:GUREVICH, DMITRY (OD)
Entity Type:Individual
Prefix:DR
First Name:DMITRY
Middle Name:
Last Name:GUREVICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 VAN SICKLEN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-2750
Mailing Address - Country:US
Mailing Address - Phone:917-449-0479
Mailing Address - Fax:
Practice Address - Street 1:1913 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1313
Practice Address - Country:US
Practice Address - Phone:917-933-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005953152W00000X
NYVUT005953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02118174Medicaid
NYC157E1Medicare ID - Type Unspecified
NY02118174Medicaid