Provider Demographics
NPI:1205378221
Name:ANDERSON, MELLISA
Entity Type:Individual
Prefix:
First Name:MELLISA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PLAZA ST E STE 1E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-4952
Mailing Address - Country:US
Mailing Address - Phone:347-564-3211
Mailing Address - Fax:347-710-1959
Practice Address - Street 1:10 PLAZA ST E STE 1E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-4952
Practice Address - Country:US
Practice Address - Phone:347-564-3211
Practice Address - Fax:347-710-1959
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226865207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY381AG1Medicare PIN