Provider Demographics
NPI:1073129110
Name:YAKUTILOVA, YELENA (PA)
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:YAKUTILOVA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 ALDERTON ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2824
Mailing Address - Country:US
Mailing Address - Phone:917-843-6436
Mailing Address - Fax:
Practice Address - Street 1:5321 FLATLANDS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2322
Practice Address - Country:US
Practice Address - Phone:718-517-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024298207K00000X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine