Provider Demographics
NPI:1851326367
Name:KOLESNIK, DMITRIY V (MD)
Entity type:Individual
Prefix:
First Name:DMITRIY
Middle Name:V
Last Name:KOLESNIK
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 1:9530 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1136
Mailing Address - Country:US
Mailing Address - Phone:718-275-7860
Mailing Address - Fax:718-275-7882
Practice Address - Street 1:9530 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1136
Practice Address - Country:US
Practice Address - Phone:718-275-7860
Practice Address - Fax:718-275-7882
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2147292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0271GUOtherMEDICARE PTAN
NY01S641OtherEMPIRE MEDICARE
NY02196023Medicaid
NY0078AJOtherMEDICARE PTAN
NY0271GUOtherMEDICARE PTAN
NY02196023Medicaid