Provider Demographics
NPI:1104933787
Name:ODNOPOZOVA, MARIYA A
Entity type:Individual
Prefix:DR
First Name:MARIYA
Middle Name:A
Last Name:ODNOPOZOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MARCUS DR
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:631-391-7887
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:157-02 CROSSBAY BLVD.
Practice Address - Street 2:MEDISYS FAMILY CARE CENTER-HOWARD BEACH
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414
Practice Address - Country:US
Practice Address - Phone:718-323-3591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221688208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02196216Medicaid
NY0105MQMedicare PIN
NYH47690Medicare UPIN