Provider Demographics
NPI:1689265811
Name:YADGAROV, EZRO
Entity Type:Individual
Prefix:
First Name:EZRO
Middle Name:
Last Name:YADGAROV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 150TH ST APT D1
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3809
Mailing Address - Country:US
Mailing Address - Phone:917-968-7874
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2594
Practice Address - Country:US
Practice Address - Phone:718-960-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-30
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY-122300000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist