Provider Demographics
NPI:1487675104
Name:ANDREA, MARY (DPM)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ANDREA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9116 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11416-2219
Mailing Address - Country:US
Mailing Address - Phone:718-482-0010
Mailing Address - Fax:718-482-0012
Practice Address - Street 1:9116 101ST AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11416-2219
Practice Address - Country:US
Practice Address - Phone:718-482-0010
Practice Address - Fax:718-482-0012
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006076-01207PE0005X
NYN006076-1213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV03629Medicare UPIN
NYPJ7371Medicare ID - Type Unspecified
NY0076TDMedicare PIN