Provider Demographics
NPI:1417161944
Name:POGORELOVA, MARIYA O (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIYA
Middle Name:O
Last Name:POGORELOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIYA
Other - Middle Name:O
Other - Last Name:SUBBOTINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50265-20207R00000X
MN73709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI60678OtherDEAN HEALTH INSURANCE
WIPOGOMAROtherMERCYCARE INSURANCE
WI1417161944OtherBCBSWI
WI34918300Medicaid
WI34918300Medicaid
IL$$$$$$$$$ 1Medicaid
WI541760733Medicare PIN
WI34918300Medicaid