Provider Demographics
NPI:1376050799
Name:MAXIMOVA, LIDIA
Entity Type:Individual
Prefix:MS
First Name:LIDIA
Middle Name:
Last Name:MAXIMOVA
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 1:536 OVINGTON AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-1723
Mailing Address - Country:US
Mailing Address - Phone:347-252-7907
Mailing Address - Fax:
Practice Address - Street 1:536 OVINGTON AVE APT 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-1723
Practice Address - Country:US
Practice Address - Phone:347-252-7907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1105874171174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist