Provider Demographics
NPI:1407948441
Name:DAVYDOV, ANGELA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:DAVYDOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93-40 QUEENS BLVD APT 3C
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:718-657-6085
Mailing Address - Fax:718-206-2352
Practice Address - Street 1:145-04 97TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435
Practice Address - Country:US
Practice Address - Phone:718-657-6085
Practice Address - Fax:718-206-2352
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225753208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02409227Medicaid
U12907Medicare UPIN