Healthcare Provider Details

I. General information

NPI: 1174445217
Provider Name (Legal Business Name): YOTAM VEREDGORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 LAKEVILLE ROAD, BUILDING D, SUITE MUI
NEW HYDE PARK NY
11042
US

IV. Provider business mailing address

16 YENNICOCK AVE
PORT WASHINGTON NY
11050
US

V. Phone/Fax

Practice location:
  • Phone: 516-734-8500
  • Fax:
Mailing address:
  • Phone: 682-380-7488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number346067
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: