Provider Demographics
NPI:1487650396
Name:COLLMAR MERENDA, DIANE (DO)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:COLLMAR MERENDA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 MARCUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1008
Mailing Address - Country:US
Mailing Address - Phone:516-622-7405
Mailing Address - Fax:516-622-7401
Practice Address - Street 1:2800 MARCUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1008
Practice Address - Country:US
Practice Address - Phone:516-622-7405
Practice Address - Fax:516-622-7401
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195532207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01626791Medicaid
NY0421TFMedicare ID - Type UnspecifiedGHI MEDICARE
NY9K5991Medicare ID - Type UnspecifiedEMPIRE MEDICARE
NY01626791Medicaid