Provider Demographics
NPI:1174857817
Name:YURYEV, MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:YURYEV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 OCEAN AVE UNIT 1F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3576
Mailing Address - Country:US
Mailing Address - Phone:718-444-7774
Mailing Address - Fax:718-444-7775
Practice Address - Street 1:2409 OCEAN AVE
Practice Address - Street 2:UNIT # 1F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3564
Practice Address - Country:US
Practice Address - Phone:718-444-7774
Practice Address - Fax:718-444-7775
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400073006OtherMEDICARE PTAN
NY03476193Medicaid