Provider Demographics
NPI:1982950077
Name:TSUKERMAN, DMITRY (BA)
Entity Type:Individual
Prefix:MR
First Name:DMITRY
Middle Name:
Last Name:TSUKERMAN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 ARCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-2707
Mailing Address - Country:US
Mailing Address - Phone:562-686-7819
Mailing Address - Fax:
Practice Address - Street 1:100 E VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1321
Practice Address - Country:US
Practice Address - Phone:714-680-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner