Provider Demographics
NPI:1225395783
Name:YAKAVONIS, MARK V (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:V
Last Name:YAKAVONIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST, SUITE 4B
Practice Address - Street 2:SHAPIRO BLDG
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-5633
Practice Address - Fax:617-414-5226
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT60004207X00000X
MA270022207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110102515AMedicaid
NH3133057Medicaid