Provider Demographics
NPI:1215119532
Name:TARASEVICH, DMITRY (MD)
Entity type:Individual
Prefix:DR
First Name:DMITRY
Middle Name:
Last Name:TARASEVICH
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 1:454 OLD STREET ROAD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1263
Mailing Address - Country:US
Mailing Address - Phone:603-924-4680
Mailing Address - Fax:603-924-4977
Practice Address - Street 1:454 OLD STREET ROAD
Practice Address - Street 2:SUITE 301
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1263
Practice Address - Country:US
Practice Address - Phone:603-924-4680
Practice Address - Fax:603-924-4977
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH15050207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH002051101OtherMEDICARE PTAN
NH32000229Medicaid