Provider Demographics
NPI:1780679530
Name:BEITYAKOV, MORDECHAI (MD)
Entity Type:Individual
Prefix:
First Name:MORDECHAI
Middle Name:
Last Name:BEITYAKOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NEJATOUAH
Other - Middle Name:
Other - Last Name:BENTYAGHOUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1455 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-5144
Mailing Address - Country:US
Mailing Address - Phone:718-376-7894
Mailing Address - Fax:718-645-3952
Practice Address - Street 1:1455 E 24TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-5144
Practice Address - Country:US
Practice Address - Phone:718-376-7894
Practice Address - Fax:718-645-3952
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203771208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01719740Medicaid