Provider Demographics
NPI:1619411303
Name:GADOL, ILDAR (LAC,OMD)
Entity Type:Individual
Prefix:
First Name:ILDAR
Middle Name:
Last Name:GADOL
Suffix:
Gender:M
Credentials:LAC,OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W 24TH ST OFC
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1503
Mailing Address - Country:US
Mailing Address - Phone:212-645-6447
Mailing Address - Fax:646-693-2253
Practice Address - Street 1:321 W 24TH ST OFC
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-1503
Practice Address - Country:US
Practice Address - Phone:212-645-6447
Practice Address - Fax:646-693-2253
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001280171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist