MEDICARE: DR. ILYA ELLIOT VAYNER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	224033	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134221484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ILYA ELLIOT VAYNER M.D.

Provider Business Mailing Address
First Line	:	3767 RICHMOND AVENUE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312
Country	:	US
Telephone Number	:	718-966-5777
Fax Number	:	718-605-3183

Provider Business Practice Location Address
First Line	:	3767 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-3827
Country	:	US
Telephone Number	:	718-966-5777
Fax Number	:	718-605-3183

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	08/21/2023

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