Provider Demographics
NPI:1578579108
Name:YACHMENYOVA, YELENA (MD)
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:YACHMENYOVA
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 1:2375 WOODWARD ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-5120
Mailing Address - Country:US
Mailing Address - Phone:215-671-9003
Mailing Address - Fax:215-671-9004
Practice Address - Street 1:2375 WOODWARD ST
Practice Address - Street 2:SUITE 115
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-5120
Practice Address - Country:US
Practice Address - Phone:215-671-9003
Practice Address - Fax:215-671-9004
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061999L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017308530001Medicaid
PA023019Medicare ID - Type Unspecified
PAG56708Medicare UPIN