Provider Demographics
NPI:1972684751
Name:FASOLYA, MAYYA (DO)
Entity type:Individual
Prefix:MS
First Name:MAYYA
Middle Name:
Last Name:FASOLYA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 E 13TH ST
Mailing Address - Street 2:APT 1D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1152
Mailing Address - Country:US
Mailing Address - Phone:718-375-5989
Mailing Address - Fax:
Practice Address - Street 1:2814 CLARENDON RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-6318
Practice Address - Country:US
Practice Address - Phone:718-469-7363
Practice Address - Fax:718-469-7551
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219839-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02137786Medicaid
NYH34985Medicare UPIN
NY5D5761Medicare ID - Type Unspecified