Provider Demographics
NPI:1538747308
Name:DEGTYAREVA, DARIA
Entity type:Individual
Prefix:
First Name:DARIA
Middle Name:
Last Name:DEGTYAREVA
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 1:2929 W 31ST ST APT 1L2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1707
Mailing Address - Country:US
Mailing Address - Phone:917-930-9033
Mailing Address - Fax:
Practice Address - Street 1:2929 W 31ST ST APT 1L2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1707
Practice Address - Country:US
Practice Address - Phone:917-930-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, MedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3000877905OtherZEM INSURANCE SOLUTIONS
NYJLJ716566894Medicaid