Provider Demographics
NPI:1760967509
Name:ANIKIN-DICK, SERGEOUS EVGENEY
Entity Type:Individual
Prefix:
First Name:SERGEOUS
Middle Name:EVGENEY
Last Name:ANIKIN-DICK
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 1:181 PEYTONS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539-3983
Mailing Address - Country:US
Mailing Address - Phone:570-439-6591
Mailing Address - Fax:
Practice Address - Street 1:2D MARINE RAIDER BATTALION PSC 20183
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-440-7714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman