Provider Demographics
NPI:1558894899
Name:ELYAGUOV, JASON YECHIEL
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:YECHIEL
Last Name:ELYAGUOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BRADHURST AVE STE 1900
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2137
Mailing Address - Country:US
Mailing Address - Phone:914-347-1900
Mailing Address - Fax:914-347-1957
Practice Address - Street 1:19 BRADHURST AVE STE 1900
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2137
Practice Address - Country:US
Practice Address - Phone:914-347-1900
Practice Address - Fax:914-347-1957
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY314979208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07125051Medicaid