Provider Demographics
NPI:1063708519
Name:SHIROKOBROD, YEVGENY (DPT)
Entity type:Individual
Prefix:DR
First Name:YEVGENY
Middle Name:
Last Name:SHIROKOBROD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5136 DORSEY HALL DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7921
Mailing Address - Country:US
Mailing Address - Phone:443-583-7093
Mailing Address - Fax:
Practice Address - Street 1:5136 DORSEY HALL DR
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7921
Practice Address - Country:US
Practice Address - Phone:443-583-7093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist