Healthcare Provider Details

I. General information

NPI: 1124466966
Provider Name (Legal Business Name): DAVID EVDOKIMOW, M.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 SOUTH FINLEY AVE.
BASKING RIDGE NJ
07920
US

IV. Provider business mailing address

96 SOUTH FINLEY AVE.
BASKING RIDGE NJ
07920
US

V. Phone/Fax

Practice location:
  • Phone: 908-221-0482
  • Fax: 908-221-0482
Mailing address:
  • Phone: 908-221-0482
  • Fax: 908-221-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID Z EVDOKIMOW
Title or Position: PRESIDENT
Credential: M.D.
Phone: 908-221-1136