Provider Demographics
NPI:1760499230
Name:DEGTYAREVA, ELLA (MD)
Entity type:Individual
Prefix:MRS
First Name:ELLA
Middle Name:
Last Name:DEGTYAREVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 25TH AVE
Mailing Address - Street 2:SUITE 1-B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214
Mailing Address - Country:US
Mailing Address - Phone:718-372-8099
Mailing Address - Fax:718-372-1068
Practice Address - Street 1:8700 25TH AVE
Practice Address - Street 2:SUITE 1-B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-5443
Practice Address - Country:US
Practice Address - Phone:718-372-8099
Practice Address - Fax:718-372-1068
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210632208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02064395Medicaid