Provider Demographics
NPI:1851003727
Name:ELNATANOVA, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:ELNATANOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14431 72ND DR
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2403
Mailing Address - Country:US
Mailing Address - Phone:917-318-6876
Mailing Address - Fax:
Practice Address - Street 1:14431 72ND DR
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-2403
Practice Address - Country:US
Practice Address - Phone:917-318-6876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF349268-01207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine