Provider Demographics
NPI:1578897021
Name:YAKUBOV, OLEG (PT)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:YAKUBOV
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 7TH AVE APT 2A
Mailing Address - Street 2:2A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3693
Mailing Address - Country:US
Mailing Address - Phone:718-369-8000
Mailing Address - Fax:718-679-9381
Practice Address - Street 1:263 7TH AVE APT 2A
Practice Address - Street 2:2A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3693
Practice Address - Country:US
Practice Address - Phone:718-369-8000
Practice Address - Fax:718-679-9381
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2010-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY62031631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400021019Medicare PIN