Provider Demographics
NPI:1376804096
Name:DERE, MELISSA ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ELLEN
Last Name:DERE
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 1:732 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11232-1306
Mailing Address - Country:US
Mailing Address - Phone:212-226-7666
Mailing Address - Fax:212-202-7988
Practice Address - Street 1:732 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232
Practice Address - Country:US
Practice Address - Phone:212-226-7666
Practice Address - Fax:212-202-7988
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2749102080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine