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NPI Code Detail

MEDICARE: MS. MAYYA FASOLYA D.O.

MEDICARE: MS. MAYYA FASOLYA D.O.
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
1207Q00000XFamily Medicine Physician219839-1NY

Other Identifiers

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

General Provider Information

NPI Number : 1972684751
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MAYYA FASOLYA D.O.
Provider Business Mailing Address
First Line : 1654 E 13TH ST
Second Line : APT 1D
City : BROOKLYN
State : NY
Zip : 11229-1152
Country : US
Telephone Number : 718-375-5989
Fax Number :
Provider Business Practice Location Address
First Line : 2814 CLARENDON RD
Second Line :
City : BROOKLYN
State : NY
Zip : 11226-6318
Country : US
Telephone Number : 718-469-7363
Fax Number : 718-469-7551
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/18/2006
Last Update Date : 11/28/2012

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