Provider Demographics
NPI:1366101693
Name:BAKHRAMOV, DMITRIY SR
Entity type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:BAKHRAMOV
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 JERICHO TPKE STE B4
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-2019
Mailing Address - Country:US
Mailing Address - Phone:917-412-7370
Mailing Address - Fax:
Practice Address - Street 1:110 JERICHO TPKE STE B4
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-2019
Practice Address - Country:US
Practice Address - Phone:917-412-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2098686332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2098686-DCAOtherSUPPLY