Healthcare Provider Details

I. General information

NPI: 1265061691
Provider Name (Legal Business Name): KEVIN YIMING YAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 E 102ND ST FL 8
NEW YORK NY
10029-5204
US

IV. Provider business mailing address

1365B CLIFTON RD NE STE B4500
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-1159
  • Fax: 332-777-0566
Mailing address:
  • Phone: 404-778-5360
  • Fax: 404-778-4849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number333715
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number333715
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: