Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080P0210X | Pediatric Nephrologist | 003556 | NY |
Y | 2080P0210X | Pediatric Nephrologist | 269800 | NY |
NPI | 1356595862 |
---|---|
Provider Name | Dmitry V Samsonov |
First Address | Hawthorne, NY 10532-7507 |
Second Address | Hawthorne, NY 10532-2140 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/11/2008 |
Last Update Date | 23/07/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03266039 | (05) | NY |