Provider Demographics
NPI:1518455187
Name:DAVYDOV, TIMUR (DPM)
Entity Type:Individual
Prefix:
First Name:TIMUR
Middle Name:
Last Name:DAVYDOV
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 EAGAN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-4103
Mailing Address - Country:US
Mailing Address - Phone:646-251-8364
Mailing Address - Fax:
Practice Address - Street 1:63 EAGAN AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-4103
Practice Address - Country:US
Practice Address - Phone:646-251-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-28
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2021019888213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program