Provider Demographics
NPI:1568643666
Name:DAFNIOTIDIS, MELANY
Entity Type:Individual
Prefix:
First Name:MELANY
Middle Name:
Last Name:DAFNIOTIDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MELANY
Other - Middle Name:
Other - Last Name:DAFNIOTIDIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2125 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4532
Mailing Address - Country:US
Mailing Address - Phone:718-932-9200
Mailing Address - Fax:718-932-4996
Practice Address - Street 1:2125 BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-4532
Practice Address - Country:US
Practice Address - Phone:718-932-9200
Practice Address - Fax:718-932-4996
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02839696Medicaid