MEDICARE: GERALD ROBERT YAGODA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	4132	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6894605	OTHER	NY	GHI
2	137695	OTHER	NY	VALUE OPTIONS

General Provider Information

NPI Number	:	1871710236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD ROBERT YAGODA PH.D.

Provider Business Mailing Address
First Line	:	9 N MAIN ST
Second Line	:
City	:	EAST HAMPTON
State	:	NY
Zip	:	11937-2632
Country	:	US
Telephone Number	:	631-329-0680
Fax Number	:	631-267-6467

Provider Business Practice Location Address
First Line	:	9 N MAIN ST
Second Line	:
City	:	EAST HAMPTON
State	:	NY
Zip	:	11937-2632
Country	:	US
Telephone Number	:	631-329-0680
Fax Number	:	631-267-6467

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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