Provider Demographics
NPI:1417287707
Name:ANDRADE, PETER (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:ANDRADE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 WATER ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-1718
Mailing Address - Country:US
Mailing Address - Phone:954-234-3811
Mailing Address - Fax:
Practice Address - Street 1:3371 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2025
Practice Address - Country:US
Practice Address - Phone:929-229-7139
Practice Address - Fax:929-229-7139
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10124900208600000X
NY293510208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1588246433OtherNPI
1780276816OtherNPI
NJ25MB10124900OtherNJ MEDICAL LICENSE
12785099OtherCAQH
NY293510OtherNY MED LICENSE
7430432372OtherNRCME
1417287707OtherNPI