Provider Demographics
NPI:1568592632
Name:POTYLITSINA, YELENA (MD)
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:POTYLITSINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YELENA
Other - Middle Name:
Other - Last Name:KARABANOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8000
Mailing Address - Street 2:DEPT 596
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:732-671-1697
Mailing Address - Fax:732-615-2439
Practice Address - Street 1:1270 HIGHWAY 35
Practice Address - Street 2:SUITE 1
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2014
Practice Address - Country:US
Practice Address - Phone:732-671-1155
Practice Address - Fax:732-671-9630
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08017300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0139980Medicaid
NJ117046DE4Medicare PIN