Provider Demographics
NPI:1902200512
Name:ASSA, ANDREJ (MD)
Entity Type:Individual
Prefix:
First Name:ANDREJ
Middle Name:
Last Name:ASSA
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 1:707 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2650
Mailing Address - Country:US
Mailing Address - Phone:845-333-3370
Mailing Address - Fax:845-333-3372
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288440207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04811767Medicaid