Provider Demographics
NPI:1982717237
Name:PODVAL, MARINA (MD)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:PODVAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4332 KISSENA BLVD
Mailing Address - Street 2:LA
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2934
Mailing Address - Country:US
Mailing Address - Phone:718-939-0609
Mailing Address - Fax:718-939-4509
Practice Address - Street 1:4332 KISSENA BLVD
Practice Address - Street 2:LA
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2934
Practice Address - Country:US
Practice Address - Phone:718-939-0609
Practice Address - Fax:718-939-4509
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY214459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02041798Medicaid
G93243Medicare UPIN
NY02041798Medicaid
NY05555Medicare PIN