Basic Information
| Provider Information | |||||||||
| NPI: | 1205171899 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDOV | ||||||||
| FirstName: | STANISLAV | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 WALL ST | ||||||||
| Address2: | C/O EQUINOX | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100052101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122270272 | ||||||||
| FaxNumber: | 2122277874 | ||||||||
| Practice Location | |||||||||
| Address1: | 2141 UTOPIA PKWY | ||||||||
| Address2: | |||||||||
| City: | WHITESTONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113574135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187670610 | ||||||||
| FaxNumber: | 7187670260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2012 | ||||||||
| LastUpdateDate: | 12/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 035925-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.