Provider Demographics
NPI:1194490250
Name:BEDERAK, DMITRY (DNP, CRNP)
Entity type:Individual
Prefix:DR
First Name:DMITRY
Middle Name:
Last Name:BEDERAK
Suffix:
Gender:M
Credentials:DNP, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 N CHARLES ST STE 4105
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6808
Mailing Address - Country:US
Mailing Address - Phone:443-629-5485
Mailing Address - Fax:
Practice Address - Street 1:6701 N CHARLES ST STE 4105
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6881
Practice Address - Country:US
Practice Address - Phone:443-849-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR204060363LA2200X, 363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care