=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992950604
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YAROSLAV DVORSKYY M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2008
-----------------------------------------------------
Last Update Date | 03/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 INDIAN CREEK DR
-----------------------------------------------------
City | WILKES BARRE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18702-7824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-855-2086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 INDIAN CREEK DR
-----------------------------------------------------
City | WILKES BARRE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18702-7824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-855-2086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MT201932
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------