Provider Demographics
NPI:1902878416
Name:PEREDO, MARINA I (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:I
Last Name:PEREDO
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 1:594 VANDERBILT PKWY
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5527
Mailing Address - Country:US
Mailing Address - Phone:631-697-2068
Mailing Address - Fax:
Practice Address - Street 1:1047 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028
Practice Address - Country:US
Practice Address - Phone:212-754-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1907161207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01836915Medicaid
NY08D841Medicare ID - Type Unspecified
NY01836915Medicaid