Provider Demographics
NPI:1508904764
Name:MARINA PODVAL PC
Entity Type:Organization
Organization Name:MARINA PODVAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PODVAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-939-0609
Mailing Address - Street 1:43-32 KISSENA BLVD. LA
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:718-939-0609
Mailing Address - Fax:718-939-4509
Practice Address - Street 1:4332 KISSENA BLVD
Practice Address - Street 2:SUITE LA
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:718-939-4509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214459207R00000X
NY241828207V00000X
NY236385-1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty