Provider Demographics
NPI:1598743007
Name:MEDEROS, MARIANO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIANO
Middle Name:
Last Name:MEDEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 SAINT NICHOLAS AVE STE E
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2296
Mailing Address - Country:US
Mailing Address - Phone:718-894-2500
Mailing Address - Fax:718-417-4535
Practice Address - Street 1:311 SAINT NICHOLAS AVE STE E
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2296
Practice Address - Country:US
Practice Address - Phone:718-894-2500
Practice Address - Fax:718-417-4535
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156182207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00947791Medicaid
NYA63694Medicare UPIN
NY66D802Medicare ID - Type Unspecified