Provider Demographics
NPI:1144435041
Name:NIKOLAVSKY, DMITRIY (MD)
Entity type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:NIKOLAVSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DMITRIY
Other - Middle Name:ALEKSANDROVICH
Other - Last Name:NIKOLAYEVSKIY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2342
Mailing Address - Country:US
Mailing Address - Phone:315-464-6106
Mailing Address - Fax:315-464-6117
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-6106
Practice Address - Fax:315-464-6117
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086420208600000X
CO49881208800000X
NY265866208800000X, 2088F0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2088F0040XAllopathic & Osteopathic PhysiciansUrologyUrogynecology and Reconstructive Pelvic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03480646Medicaid
NYJ400076696Medicare PIN