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General NPI Number Information
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NPI Number | 1518216464
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Entity Type | Organization
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Legal Business Name | TATYANA KOTLYAREVSKY MD PC
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Dates
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Enumeration Date | 09/06/2012
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Last Update Date | 09/06/2012
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Provider Practice Location Address
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Address Line | 1811 AVENUE J
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City | BROOKLYN
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State | NY
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Zip | 11230-3808
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Country | US
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Telephone | 718-253-7474
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Fax |
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Provider Business Mailing Address
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Address Line | 3720 S OCEAN BLVD APT 1402
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City | HIGHLAND BEACH
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State | FL
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Zip | 33487-3389
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Country | US
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Telephone | 561-455-4457
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TATYANA KOTLYAREVSKY
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Credential | MD
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Telephone | 718-253-7474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 165404
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License Number State | NY
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