Provider Demographics
NPI:1104848993
Name:YATSKAR, IGOR (MS, PT)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:YATSKAR
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DUDLEY ST
Mailing Address - Street 2:STE 201
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2431
Mailing Address - Country:US
Mailing Address - Phone:617-442-3462
Mailing Address - Fax:617-445-7874
Practice Address - Street 1:120 DUDLEY ST STE 201
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2431
Practice Address - Country:US
Practice Address - Phone:401-941-1347
Practice Address - Fax:617-445-7874
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY67378OtherBCBS
MAAA33405OtherHARVARD
MA0703061Medicaid
MAAA33405OtherHARVARD