Provider Demographics
NPI:1942979265
Name:BORISSOV, DMITRIY (DPT)
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:BORISSOV
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:465 SUSQUEHANNA TRL
Practice Address - Street 2:
Practice Address - City:WATSONTOWN
Practice Address - State:PA
Practice Address - Zip Code:17777-8112
Practice Address - Country:US
Practice Address - Phone:570-742-2453
Practice Address - Fax:570-742-2468
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT029619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist