Healthcare Provider Details

I. General information

NPI: 1578579108
Provider Name (Legal Business Name): YELENA YACHMENYOVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 WOODWARD ST SUITE 115
PHILADELPHIA PA
19115-5120
US

IV. Provider business mailing address

2375 WOODWARD ST SUITE 115
PHILADELPHIA PA
19115-5120
US

V. Phone/Fax

Practice location:
  • Phone: 215-671-9003
  • Fax: 215-671-9004
Mailing address:
  • Phone: 215-671-9003
  • Fax: 215-671-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD061999L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: