Provider Demographics
NPI:1235022047
Name:JEGOROV, KONSTANTINE (CSFA/CST)
Entity type:Individual
Prefix:
First Name:KONSTANTINE
Middle Name:
Last Name:JEGOROV
Suffix:
Gender:M
Credentials:CSFA/CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11688 HIDEAWAY ST
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-1101
Mailing Address - Country:US
Mailing Address - Phone:225-247-0807
Mailing Address - Fax:
Practice Address - Street 1:8585 PICARDY AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3748
Practice Address - Country:US
Practice Address - Phone:225-763-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
147775246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant