Provider Demographics
NPI:1861703399
Name:DMITRUK, IRENE (DO)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:
Last Name:DMITRUK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:201-961-2477
Mailing Address - Fax:
Practice Address - Street 1:9660 WICKER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9487
Practice Address - Country:US
Practice Address - Phone:219-365-1177
Practice Address - Fax:219-703-6662
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014502A207P00000X
IL02003817A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine