Provider Demographics
NPI:1851575724
Name:KHAZRON, DMITRIY (DO)
Entity Type:Individual
Prefix:DR
First Name:DMITRIY
Middle Name:
Last Name:KHAZRON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 EAST 7 STREET
Mailing Address - Street 2:APT. 5G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230
Mailing Address - Country:US
Mailing Address - Phone:718-338-3247
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051901183500000X
NY279834207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01580634Medicaid