Provider Demographics
NPI:1710121108
Name:ARDELJAN, MARINEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MARINEL
Middle Name:
Last Name:ARDELJAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRENTWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-665-8200
Mailing Address - Fax:631-665-8914
Practice Address - Street 1:10 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-665-8200
Practice Address - Fax:631-665-8914
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252253208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03121859Medicaid
NY03121859Medicaid