1568592632 NPI number — YELENA POTYLITSINA M.D.

Table of content: YELENA POTYLITSINA M.D. (NPI 1568592632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568592632 NPI number — YELENA POTYLITSINA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTYLITSINA
Provider First Name:
YELENA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KARABANOVA
Provider Other First Name:
YELENA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568592632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8000
Provider Second Line Business Mailing Address:
DEPT 596
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14267-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-671-1697
Provider Business Mailing Address Fax Number:
732-615-2439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1270 HIGHWAY 35
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07748-2014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-671-1155
Provider Business Practice Location Address Fax Number:
732-671-9630
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  25MA08017300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0139980 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com