Provider Demographics
NPI:1952577751
Name:DMYTRUK, DMITRI PAVLO (DO)
Entity Type:Individual
Prefix:DR
First Name:DMITRI
Middle Name:PAVLO
Last Name:DMYTRUK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CORPORATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801
Mailing Address - Country:US
Mailing Address - Phone:603-501-5584
Mailing Address - Fax:603-501-5650
Practice Address - Street 1:875 GREENLAND RD UNIT C4
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4163
Practice Address - Country:US
Practice Address - Phone:603-431-5529
Practice Address - Fax:603-436-6603
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229604208100000X
NH14493208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3084211Medicaid