Provider Demographics
NPI:1619275849
Name:SIDLETSKYY, YAROSLAV (MD)
Entity Type:Individual
Prefix:DR
First Name:YAROSLAV
Middle Name:
Last Name:SIDLETSKYY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CENTRAL AVE APT 114B
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-5600
Mailing Address - Country:US
Mailing Address - Phone:845-300-0766
Mailing Address - Fax:
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261950-1207Q00000X
NJ25MA08896000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine