Provider Demographics
NPI:1134221484
Name:VAYNER, ILYA ELLIOT (MD)
Entity type:Individual
Prefix:DR
First Name:ILYA
Middle Name:ELLIOT
Last Name:VAYNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3767 RICHMOND AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312
Mailing Address - Country:US
Mailing Address - Phone:718-966-5777
Mailing Address - Fax:718-605-3183
Practice Address - Street 1:3767 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3827
Practice Address - Country:US
Practice Address - Phone:718-966-5777
Practice Address - Fax:718-605-3183
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY224033208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02386987Medicaid