Provider Demographics
NPI:1518943786
Name:MESIDOR, MARINO (MD)
Entity type:Individual
Prefix:DR
First Name:MARINO
Middle Name:
Last Name:MESIDOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 BIRCHWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2206
Mailing Address - Country:US
Mailing Address - Phone:516-822-5109
Mailing Address - Fax:
Practice Address - Street 1:2094 PITKIN AVE
Practice Address - Street 2:EAST NEW YORK D&TC
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-3509
Practice Address - Country:US
Practice Address - Phone:718-240-0490
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01758121Medicaid