Basic Information
| Provider Information | |||||||||
| NPI: | 1093167421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEMYTOV | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | NEMYTOV | ||||||||
| OtherFirstName: | MIKHAIL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5930 SPENCER AVE | ||||||||
| Address2: | APT 2N | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104711912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9176574259 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 234 E 149TH ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104515504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185794739 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2016 | ||||||||
| LastUpdateDate: | 07/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.