Provider Demographics
NPI:1225501083
Name:NEKTALOV, YURIY (OPTICIANRY)
Entity Type:Individual
Prefix:
First Name:YURIY
Middle Name:
Last Name:NEKTALOV
Suffix:
Gender:M
Credentials:OPTICIANRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6377
Mailing Address - Country:US
Mailing Address - Phone:212-686-8666
Mailing Address - Fax:
Practice Address - Street 1:577 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6377
Practice Address - Country:US
Practice Address - Phone:212-686-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009720-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009720-1Medicaid
009720-1OtherSTATE OF NEW YORK