MEDICARE: DR. MARINA KOTLYAR O.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	152W00000X	Optometrist	OPC3908	FL
2	152WC0802X	Corneal and Contact Management Optometrist	OPC3908	FL
3	152WL0500X	Low Vision Rehabilitation Optometrist	OPC3908	FL
4	152WS0006X	Sports Vision Optometrist	OPC3908	FL
5	152WV0400X	Vision Therapy Optometrist	OPC3908	FL
6	152WX0102X	Occupational Vision Optometrist	OPC3908	FL

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	:	1164448569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARINA KOTLYAR O.D.

Provider Business Mailing Address
First Line	:	2100 BARTOW AVE
Second Line	:	SUITE 216C
City	:	BRONX
State	:	NY
Zip	:	10475-4614
Country	:	US
Telephone Number	:	718-862-3937
Fax Number	:	646-349-3252

Provider Business Practice Location Address
First Line	:	2100 BARTOW AVE
Second Line	:	SUITE 216C
City	:	BRONX
State	:	NY
Zip	:	10475-4614
Country	:	US
Telephone Number	:	718-862-3937
Fax Number	:	646-349-3252

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

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	12/18/2009

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