Provider Demographics
NPI:1952477010
Name:MARUYAMA, NANCY C (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:C
Last Name:MARUYAMA
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 1:317 E 17TH ST
Mailing Address - Street 2:FIERMAN HALL - SUITE 5F09
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3804
Mailing Address - Country:US
Mailing Address - Phone:212-420-4094
Mailing Address - Fax:212-420-4332
Practice Address - Street 1:317 E 17TH ST
Practice Address - Street 2:FIERMAN HALL - SUITE 5F09
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3804
Practice Address - Country:US
Practice Address - Phone:212-420-4094
Practice Address - Fax:212-420-4332
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1779282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02002202Medicaid
NY072R51Medicare ID - Type UnspecifiedMCR PROV. NUMBER
NMF71958Medicare UPIN