MEDICARE: YEFIM KHAYDATOV OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	63 017225	NY

General Provider Information

NPI Number	:	1093074254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YEFIM KHAYDATOV OT

Provider Business Mailing Address
First Line	:	10810 109TH AVENUE
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420
Country	:	US
Telephone Number	:	718-641-4956
Fax Number	:

Provider Business Practice Location Address
First Line	:	10810 109TH AVE
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420-1005
Country	:	US
Telephone Number	:	718-641-4956
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2012
Last Update Date	:	05/09/2012

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