Provider Demographics
NPI:1184988156
Name:GERVAGIN, DMITRIY (LMT)
Entity type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:GERVAGIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02464-1232
Mailing Address - Country:US
Mailing Address - Phone:617-828-4516
Mailing Address - Fax:
Practice Address - Street 1:44 HIGH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1232
Practice Address - Country:US
Practice Address - Phone:617-828-4516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10680225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist