Provider Demographics
NPI:1558374033
Name:MELAMEDOFF, GUSTAVO R (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:R
Last Name:MELAMEDOFF
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:70 SHRUB HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-3110
Mailing Address - Country:US
Mailing Address - Phone:516-361-9520
Mailing Address - Fax:718-267-0847
Practice Address - Street 1:2531 30TH RD STE 1A
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2624
Practice Address - Country:US
Practice Address - Phone:718-267-1102
Practice Address - Fax:718-267-0847
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-06-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY148336207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00767359Medicaid
NY00767359Medicaid
NYB88594Medicare UPIN
NY07484GMedicare PIN