Provider Demographics
NPI:1740269034
Name:MARYAMS, YELENA (OD)
Entity type:Individual
Prefix:MRS
First Name:YELENA
Middle Name:
Last Name:MARYAMS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 STUYVESANT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083
Mailing Address - Country:US
Mailing Address - Phone:908-687-0330
Mailing Address - Fax:908-687-0139
Practice Address - Street 1:900 STUYVESANT AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083
Practice Address - Country:US
Practice Address - Phone:908-687-0330
Practice Address - Fax:908-687-0139
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00583500152W00000X
NJ27TO00122500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8683682OtherCIGNA
8683682OtherCIGNA
NYC242D1Medicare ID - Type Unspecified