Provider Demographics
NPI:1215972526
Name:NOVITZKY, DIMITRI (MD)
Entity type:Individual
Prefix:DR
First Name:DIMITRI
Middle Name:
Last Name:NOVITZKY
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 1:4407 VIEUX CARRE CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3052
Mailing Address - Country:US
Mailing Address - Phone:813-390-5344
Mailing Address - Fax:386-774-1264
Practice Address - Street 1:1001 N MACDILL AVE STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607
Practice Address - Country:US
Practice Address - Phone:813-675-4849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61367207QA0505X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064781100Medicaid
FL11642OtherBLUE CROSS BLUE SHIELD
1215972526OtherMEDICARE NPI
FL11642XMedicare PIN
FL064781100Medicaid
FL330004640Medicare PIN