Provider Demographics
NPI:1518520360
Name:KOTLYAROVA, YELIZAVETA (DPM)
Entity Type:Individual
Prefix:
First Name:YELIZAVETA
Middle Name:
Last Name:KOTLYAROVA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 LAKE ELLENOR DR STE 700
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-4643
Mailing Address - Country:US
Mailing Address - Phone:407-352-2542
Mailing Address - Fax:
Practice Address - Street 1:6021 142ND AVE N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-2822
Practice Address - Country:US
Practice Address - Phone:727-431-4850
Practice Address - Fax:727-669-8417
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNONE213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111564710Medicaid