Provider Demographics
NPI:1295902617
Name:YEGOROV, ALEXANDER (PT)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:YEGOROV
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 WALCOTT AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-701-4545
Mailing Address - Fax:718-816-5297
Practice Address - Street 1:895 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-2020
Practice Address - Country:US
Practice Address - Phone:718-701-4545
Practice Address - Fax:718-816-5297
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024697225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist