Provider Demographics
NPI:1083780233
Name:MALLER, ANDREA D (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:D
Last Name:MALLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2748 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4658
Mailing Address - Country:US
Mailing Address - Phone:718-979-2200
Mailing Address - Fax:718-979-3435
Practice Address - Street 1:2748 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4658
Practice Address - Country:US
Practice Address - Phone:718-979-2200
Practice Address - Fax:718-979-3435
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006193-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTUV006193-1OtherLICENSE
NYA4000020759Medicare PIN