Healthcare Provider Details

I. General information

NPI: 1699904490
Provider Name (Legal Business Name): YEVGENIY BALAGULA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1275 YORK AVE BOX# 8
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

21 W 86TH ST APT # 507
NEW YORK NY
10024-3671
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-5809
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number251856
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: