Provider Demographics
NPI:1831456623
Name:KOTLYAR, YAN (LICENSED OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:YAN
Middle Name:
Last Name:KOTLYAR
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 NEWKIRK PLZ
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-6526
Mailing Address - Country:US
Mailing Address - Phone:718-421-7209
Mailing Address - Fax:718-421-7209
Practice Address - Street 1:6 NEWKIRK PLZ
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-6526
Practice Address - Country:US
Practice Address - Phone:718-421-7209
Practice Address - Fax:718-421-7209
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7361156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1740385194Medicaid