Provider Demographics
NPI:1295470045
Name:POLTILOV, JULIA
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:POLTILOV
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 1:20504 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2218
Mailing Address - Country:US
Mailing Address - Phone:718-464-2020
Mailing Address - Fax:
Practice Address - Street 1:7259 KISSENA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-2165
Practice Address - Country:US
Practice Address - Phone:718-263-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY009534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program