Healthcare Provider Details

I. General information

NPI: 1225342439
Provider Name (Legal Business Name): YEVGENIY LATYSHEV M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 RIDGE RD
NORTH ARLINGTON NJ
07031-6318
US

IV. Provider business mailing address

62 RIDGE RD
NORTH ARLINGTON NJ
07031-6318
US

V. Phone/Fax

Practice location:
  • Phone: 201-351-0677
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA10264000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: