1417287707 NPI number — DR. PETER ANDRADE D.O.

Table of content: DR. PETER ANDRADE D.O. (NPI 1417287707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417287707 NPI number — DR. PETER ANDRADE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDRADE
Provider First Name:
PETER
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417287707
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
265 WATER ST APT 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10038-1718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-234-3811
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3371 RICHMOND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10312-2025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
929-229-7139
Provider Business Practice Location Address Fax Number:
929-229-7139
Provider Enumeration Date:
01/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  25MB10124900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: 293510 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1588246433 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1780276816 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 25MB10124900 . This is a "NJ MEDICAL LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 12785099 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 293510 . This is a "NY MED LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7430432372 . This is a "NRCME" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1417287707 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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