Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 2019024454 | MO |
N | 2080P0202X | Pediatric Cardiologist | 2019024454 | MO |
Y | 2080P0203X | Pediatric Critical Care Doctor | 2019024454 | MO |
NPI | 1063790269 |
---|---|
Provider Name | Dr. Dzmitry Matsiukevich |
First Address | Saint Louis, MO 63110-1002 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/07/2011 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200072068 | (05) | MO |