Healthcare Provider Details

I. General information

NPI: 1417266602
Provider Name (Legal Business Name): DIANA ELISHAIYEV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

392B BEDFORD PARK BLVD
BRONX NY
10458-2415
US

IV. Provider business mailing address

10 LINDEN ST
WOODMERE NY
11598-2620
US

V. Phone/Fax

Practice location:
  • Phone: 718-684-8864
  • Fax: 718-684-8865
Mailing address:
  • Phone: 347-327-1141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number055050
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: