Provider Demographics
NPI:1336223528
Name:KOTLYAR, MAYA B (MD)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:B
Last Name:KOTLYAR
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 1:121 LAKE SHORE RD
Mailing Address - Street 2:#3
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:617-787-2445
Mailing Address - Fax:617-787-2445
Practice Address - Street 1:736 CAMBRIDGE STR
Practice Address - Street 2:ST ELIZABETH HOSPITAL MC
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02135
Practice Address - Country:US
Practice Address - Phone:617-789-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59469207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E8164GMedicare UPIN
3168611Medicare ID - Type Unspecified