1598218257 NPI number — MR. YONG DARIN WITKOVIC PHD

Table of content: MR. YONG DARIN WITKOVIC PHD (NPI 1598218257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598218257 NPI number — MR. YONG DARIN WITKOVIC PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITKOVIC
Provider First Name:
YONG
Provider Middle Name:
DARIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598218257
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
158 WEST 124TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-523-6500
Provider Business Mailing Address Fax Number:
212-523-5677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
158 WEST 124TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-523-6500
Provider Business Practice Location Address Fax Number:
212-523-5677
Provider Enumeration Date:
07/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 025837-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01536011 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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