Provider Demographics
NPI:1164448569
Name:KOTLYAR, MARINA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:KOTLYAR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 BARTOW AVE
Mailing Address - Street 2:SUITE 216C
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-4614
Mailing Address - Country:US
Mailing Address - Phone:718-862-3937
Mailing Address - Fax:646-349-3252
Practice Address - Street 1:2100 BARTOW AVE
Practice Address - Street 2:SUITE 216C
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4614
Practice Address - Country:US
Practice Address - Phone:718-862-3937
Practice Address - Fax:646-349-3252
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3908152W00000X, 152WC0802X, 152WL0500X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621051100Medicaid
FL621051100Medicaid