Provider Demographics
NPI:1205171899
Name:DAVIDOV, STANISLAV (DPT)
Entity type:Individual
Prefix:
First Name:STANISLAV
Middle Name:
Last Name:DAVIDOV
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WALL ST
Mailing Address - Street 2:C/O EQUINOX
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10005-2101
Mailing Address - Country:US
Mailing Address - Phone:212-227-0272
Mailing Address - Fax:212-227-7874
Practice Address - Street 1:2141 UTOPIA PKWY
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-4135
Practice Address - Country:US
Practice Address - Phone:718-767-0610
Practice Address - Fax:718-767-0260
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035925-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist