Provider Demographics
NPI:1639951973
Name:YAGUDAYEV, REVITAL
Entity Type:Individual
Prefix:MS
First Name:REVITAL
Middle Name:
Last Name:YAGUDAYEV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10245 62ND RD APT 5U
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1027
Mailing Address - Country:US
Mailing Address - Phone:347-596-3469
Mailing Address - Fax:
Practice Address - Street 1:10245 62ND RD APT 5U
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1027
Practice Address - Country:US
Practice Address - Phone:347-596-3469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist