Basic Information
| Provider Information | |||||||||
| NPI: | 1598497299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EFIMENKO | ||||||||
| FirstName: | IAKOV | ||||||||
| MiddleName: | VLADISLAVOVICH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EFIMENKO | ||||||||
| OtherFirstName: | IAKOV | ||||||||
| OtherMiddleName: | VLADISLAVOVICH | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 NW 6TH ST APT 1702 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331364132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544619452 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1475 W 49TH PL | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055582500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2022 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | TRN36144 | FL | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.