Provider Demographics
NPI:1275806044
Name:DAVYDOVA, OLGA (DPM)
Entity Type:Individual
Prefix:DR
First Name:OLGA
Middle Name:
Last Name:DAVYDOVA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6743 BOOTH ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2751
Mailing Address - Country:US
Mailing Address - Phone:718-896-2323
Mailing Address - Fax:718-896-2322
Practice Address - Street 1:6743 BOOTH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2751
Practice Address - Country:US
Practice Address - Phone:718-896-2323
Practice Address - Fax:718-896-2322
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006578213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03773939Medicaid