Provider Demographics
NPI:1164531182
Name:ROMANO, MARYELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:ROMANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 FIREMANS MEMORIAL DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3553
Mailing Address - Country:US
Mailing Address - Phone:845-362-8400
Mailing Address - Fax:845-362-8474
Practice Address - Street 1:1110 SOUTH AVE
Practice Address - Street 2:SUITE306
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3403
Practice Address - Country:US
Practice Address - Phone:718-761-4700
Practice Address - Fax:718-494-2767
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1575901207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB12163Medicare UPIN
MR028D442Medicare ID - Type Unspecified