Basic Information
| Provider Information | |||||||||
| NPI: | 1174171086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YUDIN | ||||||||
| FirstName: | ATHENA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1303 LIBERTY PL | ||||||||
| Address2: | |||||||||
| City: | SICKLERVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080815710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568854854 | ||||||||
| FaxNumber: | 8568854896 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 LIBERTY PL | ||||||||
| Address2: | |||||||||
| City: | SICKLERVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080815710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568854854 | ||||||||
| FaxNumber: | 8568854896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2019 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 26NJ00951900 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.