Provider Demographics
NPI:1649258286
Name:KHASAK, DMITRY (MD)
Entity type:Individual
Prefix:MR
First Name:DMITRY
Middle Name:
Last Name:KHASAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6656
Mailing Address - Street 2:DMITRY KHASAK MD
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10150
Mailing Address - Country:US
Mailing Address - Phone:201-626-4040
Mailing Address - Fax:201-626-4041
Practice Address - Street 1:77 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2556
Practice Address - Country:US
Practice Address - Phone:212-826-6999
Practice Address - Fax:201-626-4041
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1940541207N00000X
NJ25MA06377000207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01867481Medicaid
NY01867481Medicaid