Provider Demographics
NPI:1104540590
Name:ILYAYEV, KATHERINE (OD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ILYAYEV
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 113TH ST APT 6J
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4628
Mailing Address - Country:US
Mailing Address - Phone:347-249-0100
Mailing Address - Fax:
Practice Address - Street 1:7051 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4729
Practice Address - Country:US
Practice Address - Phone:718-793-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009672152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty