Provider Demographics
NPI:1639378862
Name:YAGODA, GARY (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:YAGODA
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 1:2251 PIMMIT DR
Mailing Address - Street 2:1229
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-2811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8300 GREENSBORO DR
Practice Address - Street 2:LL 100
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3605
Practice Address - Country:US
Practice Address - Phone:703-556-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202367225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist