Healthcare Provider Details

I. General information

NPI: 1952677858
Provider Name (Legal Business Name): ARKADIY YADGAROV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 07/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 PEACHTREE DUNWOODY RD SUITE300
ATLANTA GA
30342-1713
US

IV. Provider business mailing address

5505 PEACHTREE DUNWOODY RD SUITE300
ATLANTA GA
30342-1713
US

V. Phone/Fax

Practice location:
  • Phone: 404-257-0814
  • Fax: 404-843-8521
Mailing address:
  • Phone: 404-257-0814
  • Fax: 404-843-8521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number077817
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number077817
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: