Provider Demographics
NPI:1073893822
Name:ANDOLINA, PETER ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ANTHONY
Last Name:ANDOLINA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 W JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3229
Mailing Address - Country:US
Mailing Address - Phone:631-982-2022
Mailing Address - Fax:631-982-2024
Practice Address - Street 1:895 W JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3229
Practice Address - Country:US
Practice Address - Phone:631-982-2022
Practice Address - Fax:631-982-2024
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0300434208600000X
NY269587208200000X
KY04178208200000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04108898Medicaid
KY7100508950Medicaid