Provider Demographics
NPI:1811017569
Name:MORDUKHAY, EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MORDUKHAY
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 1:6393 FITCHETT ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4830
Mailing Address - Country:US
Mailing Address - Phone:917-846-9645
Mailing Address - Fax:
Practice Address - Street 1:6393 FITCHETT ST
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4830
Practice Address - Country:US
Practice Address - Phone:917-846-9645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02623265Medicaid