Provider Demographics
NPI:1356595862
Name:SAMSONOV, DMITRY V (MD)
Entity type:Individual
Prefix:
First Name:DMITRY
Middle Name:V
Last Name:SAMSONOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1020
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-7507
Mailing Address - Country:US
Mailing Address - Phone:914-493-7583
Mailing Address - Fax:914-594-4011
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:STE 1400
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-493-7583
Practice Address - Fax:914-594-4011
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0035562080P0210X
NY2698002080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03266039Medicaid
NY03266039Medicaid