Provider Demographics
NPI:1295886612
Name:NESEN, DMITRY KONSTANTINOVICH (MD)
Entity type:Individual
Prefix:DR
First Name:DMITRY
Middle Name:KONSTANTINOVICH
Last Name:NESEN
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 1:21 LEATHERSTOCKING LN
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-1115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 YORK AVE APT 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-3150
Practice Address - Country:US
Practice Address - Phone:212-289-2571
Practice Address - Fax:212-289-2579
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2206762081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2I1262Medicare PIN
H51415Medicare UPIN
NY2I1261Medicare PIN