Provider Demographics
NPI:1538319728
Name:MAMEDOVA BRAZ, YELENA (MD)
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:MAMEDOVA BRAZ
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 1:5 WEST 86TH STREET
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024
Mailing Address - Country:US
Mailing Address - Phone:212-874-0143
Mailing Address - Fax:212-957-6495
Practice Address - Street 1:5 WEST 86TH STREET
Practice Address - Street 2:SUITE 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024
Practice Address - Country:US
Practice Address - Phone:212-874-0143
Practice Address - Fax:212-957-6495
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1851852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01274024Medicaid
NYE94731Medicare UPIN