Provider Demographics
NPI:1083899017
Name:YAKUBOV, BORIS SEMENOVICH
Entity Type:Individual
Prefix:MR
First Name:BORIS
Middle Name:SEMENOVICH
Last Name:YAKUBOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-14 63RD DRIVE
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:718-896-5084
Mailing Address - Fax:718-896-1297
Practice Address - Street 1:9514 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2025
Practice Address - Country:US
Practice Address - Phone:718-896-5084
Practice Address - Fax:718-896-1297
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048454-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01562445Medicaid