Provider Demographics
NPI:1811154347
Name:DVORAK, ANDREA MARIE (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:DVORAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2342
Mailing Address - Country:US
Mailing Address - Phone:315-464-5294
Mailing Address - Fax:315-464-7238
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-5294
Practice Address - Fax:315-464-7238
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT-188524208000000X
NY2661402080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03485852Medicaid
NYJ400079041Medicare PIN