Provider Demographics
NPI:1114303435
Name:MATATOVA, YELENA
Entity Type:Individual
Prefix:MISS
First Name:YELENA
Middle Name:
Last Name:MATATOVA
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 1:1522 55TH ST
Mailing Address - Street 2:APT. 6A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-4350
Mailing Address - Country:US
Mailing Address - Phone:347-845-7067
Mailing Address - Fax:
Practice Address - Street 1:1522 55TH ST
Practice Address - Street 2:APT. 6A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-4350
Practice Address - Country:US
Practice Address - Phone:347-845-7067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist