Provider Demographics
NPI:1598218257
Name:WITKOVIC, YONG DARIN (PHD)
Entity Type:Individual
Prefix:MR
First Name:YONG
Middle Name:DARIN
Last Name:WITKOVIC
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 WEST 124TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027
Mailing Address - Country:US
Mailing Address - Phone:212-523-6500
Mailing Address - Fax:212-523-5677
Practice Address - Street 1:158 WEST 124TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027
Practice Address - Country:US
Practice Address - Phone:212-523-6500
Practice Address - Fax:212-523-5677
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY025837-01103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL