Provider Demographics
NPI:1285616425
Name:JEREVASIMEONOVA, MARIA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:JEREVASIMEONOVA
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 1:10175 NIAGARA FALLS BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14304-2941
Mailing Address - Country:US
Mailing Address - Phone:716-298-0975
Mailing Address - Fax:716-298-0956
Practice Address - Street 1:10175 NIAGARA FALLS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-2941
Practice Address - Country:US
Practice Address - Phone:716-298-0975
Practice Address - Fax:716-298-0956
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH12545Medicare UPIN