Provider Demographics
NPI:1962738534
Name:VINNIKOV, DMITRY (RPA-C)
Entity type:Individual
Prefix:MR
First Name:DMITRY
Middle Name:
Last Name:VINNIKOV
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11701 PARK LN S APT D2G
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1052
Mailing Address - Country:US
Mailing Address - Phone:917-885-5960
Mailing Address - Fax:
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3609
Practice Address - Country:US
Practice Address - Phone:718-780-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013664363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400009079OtherMEDICARE PROVIDER #