Healthcare Provider Details

I. General information

NPI: 1750066593
Provider Name (Legal Business Name): ILYA YEGUDKIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

9663 SANTA MONICA BLVD STE 883
BEVERLY HILLS CA
90210-4303
US

V. Phone/Fax

Practice location:
  • Phone: 310-786-7204
  • Fax:
Mailing address:
  • Phone: 310-786-7204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A24875
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDO3957
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: