Provider Demographics
NPI:1811192255
Name:DEMENTYEVA, YULIYA (MD)
Entity Type:Individual
Prefix:
First Name:YULIYA
Middle Name:
Last Name:DEMENTYEVA
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 1:703 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503-2621
Mailing Address - Country:US
Mailing Address - Phone:973-754-3298
Mailing Address - Fax:
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2621
Practice Address - Country:US
Practice Address - Phone:973-754-3298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-17
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA083024002084P0800X, 2084P0015X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ153079Medicaid
NJ153079Medicaid