Provider Demographics
NPI:1679521488
Name:MODEL, DMITRIY (MD)
Entity type:Individual
Prefix:DR
First Name:DMITRIY
Middle Name:
Last Name:MODEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 RACE TRACK RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259
Mailing Address - Country:US
Mailing Address - Phone:904-230-6988
Mailing Address - Fax:904-342-4028
Practice Address - Street 1:1633 RACE TRACK RD
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32259-4222
Practice Address - Country:US
Practice Address - Phone:904-230-6988
Practice Address - Fax:904-342-4028
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88320207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
81001XMedicare ID - Type Unspecified
H94250Medicare UPIN
81001ZMedicare ID - Type Unspecified