MEDICARE: DR. STELLA ILYAEV 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	207R00000X	Internal Medicine Physician	225936	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	225936-4W	OTHER	NY	WORKERS COMPENSATION
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912907742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STELLA ILYAEV M.D.

Provider Business Mailing Address
First Line	:	6411 99TH ST
Second Line	:	APT #415
City	:	REGO PARK
State	:	NY
Zip	:	11374-2654
Country	:	US
Telephone Number	:	171-899-7028
Fax Number	:

Provider Business Practice Location Address
First Line	:	5629 METROPOLITAN AVE
Second Line	:
City	:	RIDGEWOOD
State	:	NY
Zip	:	11385-1975
Country	:	US
Telephone Number	:	718-418-0300
Fax Number	:	718-418-0301

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

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	04/18/2024

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