Healthcare Provider Details

I. General information

NPI: 1124389390
Provider Name (Legal Business Name): ELYANA MATAYEVA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MAPLE STREET PULMONARY
NORWALK CT
06856
US

IV. Provider business mailing address

34 MAPLE STREET PULMONARY
NORWALK CT
06856
US

V. Phone/Fax

Practice location:
  • Phone: 718-441-4047
  • Fax:
Mailing address:
  • Phone: 718-441-4047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number63956
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number63956
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: