Provider Demographics
NPI:1962701227
Name:GEN, DMITRIY (DO)
Entity type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:GEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 E CHEVY CHASE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4197
Mailing Address - Country:US
Mailing Address - Phone:818-246-5900
Mailing Address - Fax:
Practice Address - Street 1:1560 E CHEVY CHASE DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4197
Practice Address - Country:US
Practice Address - Phone:818-246-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine