Basic Information
| Provider Information | |||||||||
| NPI: | 1104933787 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ODNOPOZOVA | ||||||||
| FirstName: | MARIYA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 MARCUS DR | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313917887 | ||||||||
| FaxNumber: | 6314544163 | ||||||||
| Practice Location | |||||||||
| Address1: | 157-02 CROSSBAY BLVD. | ||||||||
| Address2: | MEDISYS FAMILY CARE CENTER-HOWARD BEACH | ||||||||
| City: | HOWARD BEACH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183233591 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 221688 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02196216 | 05 | NY | MEDICAID |