Provider Demographics
NPI:1902928997
Name:DUDELZAK, YAKOV (MD)
Entity type:Individual
Prefix:
First Name:YAKOV
Middle Name:
Last Name:DUDELZAK
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 1:567 DONALD LN
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2615 E 16TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3805
Practice Address - Country:US
Practice Address - Phone:718-263-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243425207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
560311OtherMEDICARE
NY02870744Medicaid