Kevin Richard Dmytriw, MD

Primary specialty

Geriatric Medicine (Family Medicine) PhysicianTaxonomy code 207QG0300X

License

33539 Issued in NJ

Practice address

524 Southpark Boulevard
Jencare Neighborhood Medical South Park, LLC
Colonial Heights, VA 23834

Phone

(804) 504-7980

Fax

(804) 504-7991

NPI assigned

May 28, 2005

Last updated

Aug 14, 2014By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• PMR Virginia Holding, LLC

  dba Jencare Senior Medical Centers of Virginia

  • Specialist
  • Miami Gardens, FL
  • NPI 1083167001
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1117238400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1407974400000",
    "number": "1598768038",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "524 SOUTHPARK BOULEVARD",
            "address_2": "JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC",
            "city": "COLONIAL HEIGHTS",
            "state": "VA",
            "postal_code": "23834",
            "telephone_number": "804-504-7980",
            "fax_number": "804-504-7991"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "524 SOUTHPARK BOULEVARD",
            "address_2": "JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC",
            "city": "COLONIAL HEIGHTS",
            "state": "VA",
            "postal_code": "23834",
            "telephone_number": "804-504-7980",
            "fax_number": "804-504-7991"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DMYTRIW",
        "first_name": "KEVIN",
        "middle_name": "RICHARD",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-05-28",
        "last_updated": "2014-08-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207QG0300X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Geriatric Medicine",
            "state": "NJ",
            "license": "33539",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Geriatric Medicine (Family Medicine) Physician in Colonial Heights, VA
• Providers in Colonial Heights, VA by specialty
• Geriatric Medicine (Family Medicine) Physician in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.