Provider Demographics
NPI:1164751863
Name:DAVYDOV, ROSTISLAV (MD)
Entity Type:Individual
Prefix:
First Name:ROSTISLAV
Middle Name:
Last Name:DAVYDOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1781 E 17TH ST APT D1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-2135
Mailing Address - Country:US
Mailing Address - Phone:917-733-8967
Mailing Address - Fax:
Practice Address - Street 1:1386 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-1353
Practice Address - Country:US
Practice Address - Phone:917-652-4020
Practice Address - Fax:917-652-4022
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03543684Medicaid