Provider Demographics
NPI:1689688012
Name:DAREVSKAYA, LILYA (DO)
Entity type:Individual
Prefix:
First Name:LILYA
Middle Name:
Last Name:DAREVSKAYA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7819 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1203
Mailing Address - Country:US
Mailing Address - Phone:718-236-7550
Mailing Address - Fax:
Practice Address - Street 1:7819 19TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-1203
Practice Address - Country:US
Practice Address - Phone:718-236-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208922208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01884293Medicaid
NY552241Medicare ID - Type Unspecified
NY01884293Medicaid