Provider Demographics
NPI:1366528549
Name:POBLAGUYEV, TATYANA P (MD)
Entity type:Individual
Prefix:MS
First Name:TATYANA
Middle Name:P
Last Name:POBLAGUYEV
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 1:24 COVE LANE
Mailing Address - Street 2:UNIT 10 C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234
Mailing Address - Country:US
Mailing Address - Phone:718-283-8497
Mailing Address - Fax:718-283-6161
Practice Address - Street 1:920 48 ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219
Practice Address - Country:US
Practice Address - Phone:718-283-8497
Practice Address - Fax:718-283-6161
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2161562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02084875Medicaid
NY02096766Medicaid
87M83Medicare ID - Type Unspecified
NY02096766Medicaid
NY02084875Medicaid
87M831Medicare ID - Type Unspecified