Provider Demographics
NPI:1275540601
Name:ANDERSON, DINA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WEST ST
Mailing Address - Street 2:#27C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-1072
Mailing Address - Country:US
Mailing Address - Phone:212-786-0550
Mailing Address - Fax:
Practice Address - Street 1:131 E 65TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-7006
Practice Address - Country:US
Practice Address - Phone:212-717-8092
Practice Address - Fax:212-879-2606
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209621174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH12233Medicare UPIN