Healthcare Provider Details

I. General information

NPI: 1164448569
Provider Name (Legal Business Name): MARINA KOTLYAR O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 BARTOW AVE SUITE 216C
BRONX NY
10475-4614
US

IV. Provider business mailing address

2100 BARTOW AVE SUITE 216C
BRONX NY
10475-4614
US

V. Phone/Fax

Practice location:
  • Phone: 718-862-3937
  • Fax: 646-349-3252
Mailing address:
  • Phone: 718-862-3937
  • Fax: 646-349-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3908
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC3908
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPC3908
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberOPC3908
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPC3908
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberOPC3908
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: