Healthcare Provider Details

I. General information

NPI: 1952441420
Provider Name (Legal Business Name): IYAR MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7235 112TH ST SUITE # PR9,
FOREST HILLS NY
11375-5469
US

IV. Provider business mailing address

7235 112TH ST SUITE # PR9,
FOREST HILLS NY
11375-5469
US

V. Phone/Fax

Practice location:
  • Phone: 877-849-4917
  • Fax: 877-949-4917
Mailing address:
  • Phone: 877-849-4917
  • Fax: 877-949-4917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number233906
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number030904
License Number StateNY

VIII. Authorized Official

Name: DR. NIKOLAI LAGODUKE
Title or Position: OWNER
Credential: MD
Phone: 877-849-4917