=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265788921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATALIA POTAPOVA OPHTHALMOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2012
-----------------------------------------------------
Last Update Date | 07/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9777 QUEENS BLVD
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-3335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-809-7727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 E 23RD ST STE 16
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-4474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-809-7727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NATALIA POTAPOVA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 203-809-7727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------