Provider Demographics
NPI:1417390568
Name:KHOLDAROVA, MARINA
Entity Type:Individual
Prefix:MS
First Name:MARINA
Middle Name:
Last Name:KHOLDAROVA
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 1:7527 194TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1837
Mailing Address - Country:US
Mailing Address - Phone:646-327-5031
Mailing Address - Fax:
Practice Address - Street 1:7527 194TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1837
Practice Address - Country:US
Practice Address - Phone:646-327-5031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY703488131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist