Basic Information
| Provider Information | |||||||||
| NPI: | 1003144528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIREYEV | ||||||||
| FirstName: | DMITRIY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 GARLAND ST | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021495066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813947731 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 GARLAND ST | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021495066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813947731 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 250579-1 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 245639 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 110087726A | 05 | MA | MEDICAID |