Provider Demographics
NPI:1043220262
Name:DEMEO, ROBERT RUDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RUDOLPH
Last Name:DEMEO
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 1:522 TYSENS LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4241
Mailing Address - Country:US
Mailing Address - Phone:718-667-2156
Mailing Address - Fax:718-668-1468
Practice Address - Street 1:522 TYSENS LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4241
Practice Address - Country:US
Practice Address - Phone:718-667-2156
Practice Address - Fax:718-668-1468
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121217174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0C5855OtherTOUCHSTONE
NY0017704OtherGHI
NY0S234OtherOXFORD
NY25320POtherHIP
NY056343OtherAETNA
NYRD037D5310OtherBLUE CROSS
NY00870755Medicaid
NYC09265Medicare UPIN
NYRD037D5310Medicare ID - Type UnspecifiedMEDICARE