Provider Demographics
NPI:1265036636
Name:YTSHAKOV, SIGAL L
Entity Type:Individual
Prefix:
First Name:SIGAL
Middle Name:L
Last Name:YTSHAKOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 DICKENS ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2407
Mailing Address - Country:US
Mailing Address - Phone:516-526-0667
Mailing Address - Fax:
Practice Address - Street 1:1016 DICKENS ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2407
Practice Address - Country:US
Practice Address - Phone:516-526-0667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1445599201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY744937450-00OtherFIDELIS CARE