Provider Demographics
NPI:1760557797
Name:MARBALLI, PRADEEP D (MD)
Entity Type:Individual
Prefix:DR
First Name:PRADEEP
Middle Name:D
Last Name:MARBALLI
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Gender:M
Credentials:MD
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Mailing Address - Street 1:427 GUY PARK AVENUE
Mailing Address - Street 2:ST MARYS HOSPITAL BEHAVIORAL HEALTH
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-843-7520
Mailing Address - Fax:518-843-7537
Practice Address - Street 1:8 NORTHAMPTON
Practice Address - Street 2:ST MARYS HOSPITAL CHILDRENS MENTAL HEALTH CLINIC
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010
Practice Address - Country:US
Practice Address - Phone:518-843-7520
Practice Address - Fax:518-843-7537
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
NY1787392084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02605356Medicaid
NY02605356Medicaid
F03302Medicare UPIN