Provider Demographics
NPI:1073512927
Name:DYAKOVETSKY, IZABELLA (MD)
Entity Type:Individual
Prefix:
First Name:IZABELLA
Middle Name:
Last Name:DYAKOVETSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:RICHBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18954-1660
Mailing Address - Country:US
Mailing Address - Phone:215-718-8036
Mailing Address - Fax:
Practice Address - Street 1:54 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:RICHBORO
Practice Address - State:PA
Practice Address - Zip Code:18954-1660
Practice Address - Country:US
Practice Address - Phone:215-718-8036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066483L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01884662Medicaid
PA052936Medicare ID - Type Unspecified
PA01884662Medicaid