Provider Demographics
NPI:1407821309
Name:AMITINA, MARINA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:AMITINA
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 1:3525 77TH ST APT A58
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-4542
Mailing Address - Country:US
Mailing Address - Phone:917-757-3605
Mailing Address - Fax:718-939-4509
Practice Address - Street 1:4332 KISSENA BLVD STE LA
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2934
Practice Address - Country:US
Practice Address - Phone:718-939-0609
Practice Address - Fax:718-939-0609
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225539-1N2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02445150Medicaid
NY02445150Medicaid
NY07856JMedicare PIN
NY08278HMedicare PIN
NY563N2G2841Medicare PIN