Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RG0100X | Gastroenterologist | 25MA065097 | NJ |
N | 207RG0100X | Gastroenterologist | 51971 | KY |
Y | 207RG0100X | Gastroenterologist | ME142694 | FL |
NPI | 1033105903 |
---|---|
Provider Name | Dmitry Mysh |
First Address | Fort Myers, FL 33902-2147 |
Second Address | Fort Myers, FL 33908-9621 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2005 |
Last Update Date | 30/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
104397900 | (05) | FL |
8503206 | (05) | NJ |
H02847 | (02) | NJ |