Provider Demographics
NPI:1700099983
Name:KHODAKOV, YURI (MD)
Entity type:Individual
Prefix:DR
First Name:YURI
Middle Name:
Last Name:KHODAKOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-2650
Mailing Address - Fax:801-387-2655
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:SUITE 3490
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-2650
Practice Address - Fax:801-387-2655
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6656163-1205207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1114055241Medicaid
UT000063355Medicare PIN
000061395Medicare PIN