Provider Demographics
NPI:1043509227
Name:PEREDO, ANDREW L (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:L
Last Name:PEREDO
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 1:110 E MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2845
Mailing Address - Country:US
Mailing Address - Phone:631-424-3600
Mailing Address - Fax:
Practice Address - Street 1:110 E MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2845
Practice Address - Country:US
Practice Address - Phone:631-424-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2020-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280821-1390200000X, 208200000X
CODR.0058741390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program