Provider Demographics
NPI:1215157987
Name:DYAKOVETSKY, YEVGENIY
Entity type:Individual
Prefix:DR
First Name:YEVGENIY
Middle Name:
Last Name:DYAKOVETSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:EUGENE
Other - Middle Name:
Other - Last Name:DYAKOVETSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:54 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:RICHBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18954-1660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:RICHBORO
Practice Address - State:PA
Practice Address - Zip Code:18954-1660
Practice Address - Country:US
Practice Address - Phone:215-939-1452
Practice Address - Fax:215-579-4767
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071330L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA040874Medicare ID - Type UnspecifiedPROVIDER NUMBER
H22633Medicare UPIN