Provider Demographics
NPI:1205993334
Name:KHANIN, YURIY (MD)
Entity type:Individual
Prefix:
First Name:YURIY
Middle Name:
Last Name:KHANIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10753 GUY R BREWER BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-2351
Mailing Address - Country:US
Mailing Address - Phone:718-523-5776
Mailing Address - Fax:
Practice Address - Street 1:10753 GUY R BREWER BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-2351
Practice Address - Country:US
Practice Address - Phone:718-523-5776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230941208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02554736Medicaid
NY02554736Medicaid
07559Medicare ID - Type Unspecified