Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | ME61367 | FL |
NPI | 1215972526 |
---|---|
Provider Name | Dr. Dimitri Novitzky |
First Address | Tampa, FL 33613-3052 |
Second Address | Tampa, FL 33607 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2006 |
Last Update Date | 27/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
064781100 | (05) | FL |
11642 | BLUE CROSS BLUE SHIELD (01) | FL |
1215972526 | MEDICARE NPI (01) | |
C95307 | (02) | FL |