MEDICARE: MR. YAN KOTLYAR LICENSED OPTICIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	7361	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831456623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. YAN KOTLYAR LICENSED OPTICIAN

Provider Business Mailing Address
First Line	:	6 NEWKIRK PLZ
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-6526
Country	:	US
Telephone Number	:	718-421-7209
Fax Number	:	718-421-7209

Provider Business Practice Location Address
First Line	:	6 NEWKIRK PLZ
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-6526
Country	:	US
Telephone Number	:	718-421-7209
Fax Number	:	718-421-7209

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2012
Last Update Date	:	04/18/2012

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