Provider Demographics
NPI:1023451010
Name:BLEDNOVA, DARYA (MD)
Entity type:Individual
Prefix:DR
First Name:DARYA
Middle Name:
Last Name:BLEDNOVA
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 1:6511 BOOTH ST SUITE 1C
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4181
Mailing Address - Country:US
Mailing Address - Phone:718-806-1434
Mailing Address - Fax:718-806-1435
Practice Address - Street 1:10151 SE SUNNYSIDE RD STE 100
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5705
Practice Address - Country:US
Practice Address - Phone:503-659-0880
Practice Address - Fax:503-513-7425
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285150207R00000X
ORMD214121207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYFB6140494OtherDEA