Provider Demographics
NPI:1023128402
Name:SHELCHKOV, DMITRY A (MD)
Entity type:Individual
Prefix:
First Name:DMITRY
Middle Name:A
Last Name:SHELCHKOV
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:PO BOX 650782
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0782
Mailing Address - Country:US
Mailing Address - Phone:302-733-0806
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:1505 W SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6912
Practice Address - Country:US
Practice Address - Phone:856-641-8000
Practice Address - Fax:877-329-2370
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08127900207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ38314OtherABA CERTIFICATE #
NJP00678791OtherRAILROAD MEDICARE
NJ105467Medicare PIN
NJ38314OtherABA CERTIFICATE #