Provider Demographics
NPI:1831921048
Name:YAKUBOVA, SHOSHANA
Entity type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:
Last Name:YAKUBOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6351 ELLWELL CRES
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4828
Mailing Address - Country:US
Mailing Address - Phone:917-605-0402
Mailing Address - Fax:
Practice Address - Street 1:6373 108TH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1607
Practice Address - Country:US
Practice Address - Phone:718-896-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYORT010010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist