Provider Demographics
NPI:1427026392
Name:MARINA I PEREDO MD PC
Entity Type:Organization
Organization Name:MARINA I PEREDO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:I
Authorized Official - Last Name:PEREDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:631-863-3221
Mailing Address - Street 1:260 MIDDLE COUNTRY RD
Mailing Address - Street 2:STE 208
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-863-3223
Mailing Address - Fax:631-863-3334
Practice Address - Street 1:260 MIDDLE COUNTRY RD
Practice Address - Street 2:STE 208
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-863-3223
Practice Address - Fax:631-863-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190716207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01836915Medicaid
08D841Medicare ID - Type Unspecified
NYG07692Medicare UPIN