Provider Demographics
NPI:1811095714
Name:ELIZA, MARIEL (MD)
Entity type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:ELIZA
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:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-0404
Mailing Address - Country:US
Mailing Address - Phone:516-234-0073
Mailing Address - Fax:
Practice Address - Street 1:400 S OYSTER BAY RD STE 100
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3500
Practice Address - Country:US
Practice Address - Phone:516-234-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241647208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW2L252Medicare PIN
NYW2L251Medicare PIN