Healthcare Provider Details

I. General information

NPI: 1043509227
Provider Name (Legal Business Name): ANDREW L PEREDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 07/19/2020
Certification Date: 07/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E MAIN ST STE 6
HUNTINGTON NY
11743-2845
US

IV. Provider business mailing address

110 E MAIN ST STE 6
HUNTINGTON NY
11743-2845
US

V. Phone/Fax

Practice location:
  • Phone: 631-424-3600
  • Fax:
Mailing address:
  • Phone: 631-424-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number280821-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDR.0058741
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number280821-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: