Provider Demographics
NPI:1912907742
Name:ILYAEV, STELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:STELLA
Middle Name:
Last Name:ILYAEV
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 1:6411 99TH ST
Mailing Address - Street 2:APT #415
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2654
Mailing Address - Country:US
Mailing Address - Phone:171-899-7028
Mailing Address - Fax:
Practice Address - Street 1:5629 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1975
Practice Address - Country:US
Practice Address - Phone:718-418-0300
Practice Address - Fax:718-418-0301
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225936207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY225936-4WOtherWORKERS COMPENSATION
NY02361360Medicaid
NY02361360Medicaid
NY08278IMedicare PIN