Provider Demographics
NPI:1942460753
Name:EUGENE DYAKOVETSKY MD. LLC
Entity Type:Organization
Organization Name:EUGENE DYAKOVETSKY MD. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DYAKOVETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-471-0089
Mailing Address - Street 1:201 LAKESIDE PARK
Mailing Address - Street 2:STE A
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-4049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 LAKESIDE PARK
Practice Address - Street 2:STE A
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-4049
Practice Address - Country:US
Practice Address - Phone:215-322-1058
Practice Address - Fax:215-322-1059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
040874Medicare PIN