Basic Information
| Provider Information | |||||||||
| NPI: | 1861703399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DMITRUK | ||||||||
| FirstName: | IRENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019612477 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9660 WICKER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463739487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193651177 | ||||||||
| FaxNumber: | 2197036662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2010 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 11014502A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 02003817A | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.