Provider Demographics
NPI:1417992322
Name:KHAYLOMSKAYA, MARA (MD)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:KHAYLOMSKAYA
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 1:1 PARK AVE
Mailing Address - Street 2:10TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5802
Mailing Address - Country:US
Mailing Address - Phone:646-754-4506
Mailing Address - Fax:212-307-0759
Practice Address - Street 1:1 PARK AVE
Practice Address - Street 2:10TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5802
Practice Address - Country:US
Practice Address - Phone:646-754-4506
Practice Address - Fax:212-307-0759
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211036207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01878284Medicaid
NY01878284Medicaid
NY56N921Medicare ID - Type Unspecified