Provider Demographics
NPI:1134442999
Name:DIMICH, IVAN G (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:G
Last Name:DIMICH
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 1:201EAST79THSTREETSUITE20E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0836
Mailing Address - Country:US
Mailing Address - Phone:212-734-8232
Mailing Address - Fax:
Practice Address - Street 1:201EAST79THSTREETSUITE
Practice Address - Street 2:20 E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0836
Practice Address - Country:US
Practice Address - Phone:212-734-8232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10455712080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB20370Medicare UPIN