Provider Demographics
NPI:1184158602
Name:DMITRUK, SERGEI VENIAMINOVICH (MD)
Entity type:Individual
Prefix:
First Name:SERGEI
Middle Name:VENIAMINOVICH
Last Name:DMITRUK
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 1:1935 BLUEGRASS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1181
Mailing Address - Country:US
Mailing Address - Phone:502-364-0033
Mailing Address - Fax:502-361-4488
Practice Address - Street 1:4010 DUPONT CIR STE 380
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4881
Practice Address - Country:US
Practice Address - Phone:502-895-0040
Practice Address - Fax:502-214-3429
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01085592A207W00000X
KY54890207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100740700Medicaid
IN300050894Medicaid