Provider Demographics
NPI:1538583695
Name:OSTRO, DMITRY
Entity type:Individual
Prefix:
First Name:DMITRY
Middle Name:
Last Name:OSTRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 DOCKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GAMALIEL
Mailing Address - State:AR
Mailing Address - Zip Code:72537-7200
Mailing Address - Country:US
Mailing Address - Phone:646-431-8273
Mailing Address - Fax:
Practice Address - Street 1:145 DOCKSIDE DR
Practice Address - Street 2:
Practice Address - City:GAMALIEL
Practice Address - State:AR
Practice Address - Zip Code:72537-7200
Practice Address - Country:US
Practice Address - Phone:646-431-8273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR229606367500000X
NJ26NJ01145900367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty