Healthcare Provider Details

I. General information

NPI: 1710794805
Provider Name (Legal Business Name): YURIY DIDUKH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 02/12/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 RIDGEWAY AVE STE 220
ROCHESTER NY
14626-4296
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-368-4560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number311791
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: