Provider Demographics
NPI:1740817774
Name:PERESADA, DMITRIY (MD)
Entity type:Individual
Prefix:DR
First Name:DMITRIY
Middle Name:
Last Name:PERESADA
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 1:9350 SKOKIE BLVD UNIT 505
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-5600
Mailing Address - Country:US
Mailing Address - Phone:312-217-5806
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program